Pharmacotherapy Management of Acute Migraine in the Emergency Department

Migraine is an often-disabling condition and a common presentation to the Emergency Department (ED). Rapid and effective treatment are essential to reduce symptom burden, prevent recurrence, and improve patient outcomes. This review provides a comprehensive, evidence-based overview of the pharmacologic management of acute migraine in the ED, including first-line therapies, rescue medications, adjunctive care strategies, and considerations for special populations. First-line agents for acute migraine include dopamine antagonists, nonsteroidal anti-inflammatory drugs, and triptans, with treatment tailored to severity, comorbidities, and previous response. Rescue therapies such as dexamethasone, valproic acid, magnesium sulfate, and, in rare cases, dihydroergotamine and caffeine, are indicated for refractory or recurrent symptoms. Supportive interventions such as intravenous fluids and antiemetics can enhance treatment response. Special populations, including pregnant individuals, pediatric, and geriatric patients, as well as those with cardiovascular disease, require individualized management. It is critical for ED personnel to provide not only optimal pharmacotherapy but also safe medication administration, astute monitoring for adverse effects, and the provision of discharge education to prevent migraine recurrence and ensure outpatient follow-up.