2025 guideline update to acute treatment of migraine for adults in the emergency department: The American Headache Society evidence assessment of parenteral pharmacotherapies.
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| Title: | 2025 guideline update to acute treatment of migraine for adults in the emergency department: The American Headache Society evidence assessment of parenteral pharmacotherapies. |
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| Authors: | Robblee, Jennifer (AUTHOR), Minen, Mia T. (AUTHOR), Friedman, Benjamin W. (AUTHOR), Cortel‐LeBlanc, Miguel A. (AUTHOR), Cortel‐LeBlanc, Achelle (AUTHOR), Orr, Serena L. (AUTHOR) |
| Source: | Headache: The Journal of Head & Face Pain. Jan2026, Vol. 66 Issue 1, p53-76. 24p. |
| Subjects: | Medical protocols, Medical information storage & retrieval systems, Adrenocortical hormones, Sumatriptan, Morphine, Headache, Hospital emergency services, Meta-analysis, Treatment effectiveness, Parenteral infusions, Systematic reviews, MEDLINE, Prochlorperazine, Propofol, Drug efficacy, Medical databases, Chlorpromazine, Ketorolac, Disease relapse, Metoclopramide, Migraine, Nerve block, Dexamethasone, Acetaminophen, Adults |
| Geographic Terms: | United States |
| Abstract: | Objective: To update the 2016 American Headache Society (AHS) guideline on parenteral pharmacologic therapies for the management of migraine attacks in the emergency department (ED). Methods: We conducted a systematic review and meta‐analysis using the same methodology as the 2016 guideline. The original search strategy was repeated and expanded to include studies of nerve blocks and sphenopalatine ganglion (SPG) blocks. We searched Medline, Embase, Cochrane, clinicaltrials.gov, and the World Health Organization (WHO) International Clinical Trials Registry Platform through February 10, 2025. Eligible studies were randomized controlled trials (RCTs) involving adults diagnosed with migraine, treated in the ED with intravenous (IV), intramuscular (IM), subcutaneous (SC), or nerve block (including SPG block) interventions. Two reviewers independently screened titles/abstracts and full texts; a third reviewer resolved disagreements. Data were extracted using a standardized form and verified by a second reviewer. Risk of bias was assessed using the American Academy of Neurology (AAN) criteria. Where applicable, meta‐analyses were performed. Efficacy was categorized as highly likely, likely, or possibly effective or ineffective. Clinical recommendations were developed using the AAN guideline development process. Results: The search identified 26 new RCTs evaluating 20 injectable treatments. Of these, 12 were rated class I (low risk of bias), 9 class II, and 4 class III. Prochlorperazine IV, dexketoprofen IV, sumatriptan SC, and greater occipital nerve blocks (GONB) were considered highly likely to be effective based on multiple class I studies. Chlorpromazine IV, metoclopramide IV, eptinezumab IV, ketorolac IV, and supraorbital nerve blocks (SONB) were considered likely effective based on one class I or multiple class II studies. Hydromorphone IV, propofol IV, and paracetamol IV were considered likely ineffective based on class I or multiple class II studies. After review of the evidence and a consensus process, recommendations were made for each intervention. Conclusions: Prochlorperazine IV and GONB must be offered to eligible adults presenting to the ED with a migraine attack for treatment of headache requiring parenteral therapy (level A – must offer) in those without contraindications, while hydromorphone IV must not be offered (level A – must not offer). Treatments that should be offered when appropriate (level B – should offer) include dexketoprofen IV, ketorolac IV, metoclopramide IV, sumatriptan SC, and SONB. Chlorpromazine IV, dexamethasone IV, and valproate IV may be offered (level C – may offer). Paracetamol IV may not be offered (level C – should not offer). Eptinezumab should be offered (level B) only for patients matching the clinical trial population but is rated level U – no recommendation for an ED‐specific population. Additional evidence is needed for caffeine, granisetron, ibuprofen, ketamine, lidocaine, normal saline, propofol, and SPG blocks, all currently rated level U – no recommendation. Plain Language Summary: Migraine is a common cause of emergency department (ED) visits due to headache, but treatments offered in the ED can vary. This paper presents updated clinical practice guidelines for managing migraine attacks in the ED, which were informed by new clinical trial data evaluating treatments for migraine attacks in the ED and a rigorous review process. This updated review found that: (1) intravenous prochlorperazine and greater occipital nerve blocks had the strongest evidence and must be offered to patients in the ED; (2) several other treatments were found to be helpful and should be offered; and (3) intravenous opioids and intravenous paracetamol/acetaminophen are not recommended for migraine‐related pain relief. [ABSTRACT FROM AUTHOR] |
| Copyright of Headache: The Journal of Head & Face Pain is the property of Wiley-Blackwell and its content may not be copied or emailed to multiple sites without the copyright holder's express written permission. Additionally, content may not be used with any artificial intelligence tools or machine learning technologies. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.) | |
| Database: | Psychology and Behavioral Sciences Collection |
| FullText | Text: Availability: 0 |
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| Header | DbId: pbh DbLabel: Psychology and Behavioral Sciences Collection An: 191181541 AccessLevel: 6 PubType: Academic Journal PubTypeId: academicJournal PreciseRelevancyScore: 0 |
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| Items | – Name: Title Label: Title Group: Ti Data: 2025 guideline update to acute treatment of migraine for adults in the emergency department: The American Headache Society evidence assessment of parenteral pharmacotherapies. – Name: Author Label: Authors Group: Au Data: <searchLink fieldCode="AR" term="%22Robblee%2C+Jennifer%22">Robblee, Jennifer</searchLink> (AUTHOR)<br /><searchLink fieldCode="AR" term="%22Minen%2C+Mia+T%2E%22">Minen, Mia T.</searchLink> (AUTHOR)<br /><searchLink fieldCode="AR" term="%22Friedman%2C+Benjamin+W%2E%22">Friedman, Benjamin W.</searchLink> (AUTHOR)<br /><searchLink fieldCode="AR" term="%22Cortel‐LeBlanc%2C+Miguel+A%2E%22">Cortel‐LeBlanc, Miguel A.</searchLink> (AUTHOR)<br /><searchLink fieldCode="AR" term="%22Cortel‐LeBlanc%2C+Achelle%22">Cortel‐LeBlanc, Achelle</searchLink> (AUTHOR)<br /><searchLink fieldCode="AR" term="%22Orr%2C+Serena+L%2E%22">Orr, Serena L.</searchLink> (AUTHOR) – Name: TitleSource Label: Source Group: Src Data: <searchLink fieldCode="JN" term="%22Headache%3A+The+Journal+of+Head+%26+Face+Pain%22">Headache: The Journal of Head & Face Pain</searchLink>. Jan2026, Vol. 66 Issue 1, p53-76. 24p. – Name: Subject Label: Subjects Group: Su Data: <searchLink fieldCode="DE" term="%22Medical+protocols%22">Medical protocols</searchLink><br /><searchLink fieldCode="DE" term="%22Medical+information+storage+%26+retrieval+systems%22">Medical information storage & retrieval systems</searchLink><br /><searchLink fieldCode="DE" term="%22Adrenocortical+hormones%22">Adrenocortical hormones</searchLink><br /><searchLink fieldCode="DE" term="%22Sumatriptan%22">Sumatriptan</searchLink><br /><searchLink fieldCode="DE" term="%22Morphine%22">Morphine</searchLink><br /><searchLink fieldCode="DE" term="%22Headache%22">Headache</searchLink><br /><searchLink fieldCode="DE" term="%22Hospital+emergency+services%22">Hospital emergency services</searchLink><br /><searchLink fieldCode="DE" term="%22Meta-analysis%22">Meta-analysis</searchLink><br /><searchLink fieldCode="DE" term="%22Treatment+effectiveness%22">Treatment effectiveness</searchLink><br /><searchLink fieldCode="DE" term="%22Parenteral+infusions%22">Parenteral infusions</searchLink><br /><searchLink fieldCode="DE" term="%22Systematic+reviews%22">Systematic reviews</searchLink><br /><searchLink fieldCode="DE" term="%22MEDLINE%22">MEDLINE</searchLink><br /><searchLink fieldCode="DE" term="%22Prochlorperazine%22">Prochlorperazine</searchLink><br /><searchLink fieldCode="DE" term="%22Propofol%22">Propofol</searchLink><br /><searchLink fieldCode="DE" term="%22Drug+efficacy%22">Drug efficacy</searchLink><br /><searchLink fieldCode="DE" term="%22Medical+databases%22">Medical databases</searchLink><br /><searchLink fieldCode="DE" term="%22Chlorpromazine%22">Chlorpromazine</searchLink><br /><searchLink fieldCode="DE" term="%22Ketorolac%22">Ketorolac</searchLink><br /><searchLink fieldCode="DE" term="%22Disease+relapse%22">Disease relapse</searchLink><br /><searchLink fieldCode="DE" term="%22Metoclopramide%22">Metoclopramide</searchLink><br /><searchLink fieldCode="DE" term="%22Migraine%22">Migraine</searchLink><br /><searchLink fieldCode="DE" term="%22Nerve+block%22">Nerve block</searchLink><br /><searchLink fieldCode="DE" term="%22Dexamethasone%22">Dexamethasone</searchLink><br /><searchLink fieldCode="DE" term="%22Acetaminophen%22">Acetaminophen</searchLink><br /><searchLink fieldCode="DE" term="%22Adults%22">Adults</searchLink> – Name: SubjectGeographic Label: Geographic Terms Group: Su Data: <searchLink fieldCode="DE" term="%22United+States%22">United States</searchLink> – Name: Abstract Label: Abstract Group: Ab Data: Objective: To update the 2016 American Headache Society (AHS) guideline on parenteral pharmacologic therapies for the management of migraine attacks in the emergency department (ED). Methods: We conducted a systematic review and meta‐analysis using the same methodology as the 2016 guideline. The original search strategy was repeated and expanded to include studies of nerve blocks and sphenopalatine ganglion (SPG) blocks. We searched Medline, Embase, Cochrane, clinicaltrials.gov, and the World Health Organization (WHO) International Clinical Trials Registry Platform through February 10, 2025. Eligible studies were randomized controlled trials (RCTs) involving adults diagnosed with migraine, treated in the ED with intravenous (IV), intramuscular (IM), subcutaneous (SC), or nerve block (including SPG block) interventions. Two reviewers independently screened titles/abstracts and full texts; a third reviewer resolved disagreements. Data were extracted using a standardized form and verified by a second reviewer. Risk of bias was assessed using the American Academy of Neurology (AAN) criteria. Where applicable, meta‐analyses were performed. Efficacy was categorized as highly likely, likely, or possibly effective or ineffective. Clinical recommendations were developed using the AAN guideline development process. Results: The search identified 26 new RCTs evaluating 20 injectable treatments. Of these, 12 were rated class I (low risk of bias), 9 class II, and 4 class III. Prochlorperazine IV, dexketoprofen IV, sumatriptan SC, and greater occipital nerve blocks (GONB) were considered highly likely to be effective based on multiple class I studies. Chlorpromazine IV, metoclopramide IV, eptinezumab IV, ketorolac IV, and supraorbital nerve blocks (SONB) were considered likely effective based on one class I or multiple class II studies. Hydromorphone IV, propofol IV, and paracetamol IV were considered likely ineffective based on class I or multiple class II studies. After review of the evidence and a consensus process, recommendations were made for each intervention. Conclusions: Prochlorperazine IV and GONB must be offered to eligible adults presenting to the ED with a migraine attack for treatment of headache requiring parenteral therapy (level A – must offer) in those without contraindications, while hydromorphone IV must not be offered (level A – must not offer). Treatments that should be offered when appropriate (level B – should offer) include dexketoprofen IV, ketorolac IV, metoclopramide IV, sumatriptan SC, and SONB. Chlorpromazine IV, dexamethasone IV, and valproate IV may be offered (level C – may offer). Paracetamol IV may not be offered (level C – should not offer). Eptinezumab should be offered (level B) only for patients matching the clinical trial population but is rated level U – no recommendation for an ED‐specific population. Additional evidence is needed for caffeine, granisetron, ibuprofen, ketamine, lidocaine, normal saline, propofol, and SPG blocks, all currently rated level U – no recommendation. Plain Language Summary: Migraine is a common cause of emergency department (ED) visits due to headache, but treatments offered in the ED can vary. This paper presents updated clinical practice guidelines for managing migraine attacks in the ED, which were informed by new clinical trial data evaluating treatments for migraine attacks in the ED and a rigorous review process. This updated review found that: (1) intravenous prochlorperazine and greater occipital nerve blocks had the strongest evidence and must be offered to patients in the ED; (2) several other treatments were found to be helpful and should be offered; and (3) intravenous opioids and intravenous paracetamol/acetaminophen are not recommended for migraine‐related pain relief. [ABSTRACT FROM AUTHOR] – Name: AbstractSuppliedCopyright Label: Group: Ab Data: <i>Copyright of Headache: The Journal of Head & Face Pain is the property of Wiley-Blackwell and its content may not be copied or emailed to multiple sites without the copyright holder's express written permission. Additionally, content may not be used with any artificial intelligence tools or machine learning technologies. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract.</i> (Copyright applies to all Abstracts.) |
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| RecordInfo | BibRecord: BibEntity: Identifiers: – Type: doi Value: 10.1111/head.70016 Languages: – Code: eng Text: English PhysicalDescription: Pagination: PageCount: 24 StartPage: 53 Subjects: – SubjectFull: Medical protocols Type: general – SubjectFull: Medical information storage & retrieval systems Type: general – SubjectFull: Adrenocortical hormones Type: general – SubjectFull: Sumatriptan Type: general – SubjectFull: Morphine Type: general – SubjectFull: Headache Type: general – SubjectFull: Hospital emergency services Type: general – SubjectFull: Meta-analysis Type: general – SubjectFull: Treatment effectiveness Type: general – SubjectFull: Parenteral infusions Type: general – SubjectFull: Systematic reviews Type: general – SubjectFull: MEDLINE Type: general – SubjectFull: Prochlorperazine Type: general – SubjectFull: Propofol Type: general – SubjectFull: Drug efficacy Type: general – SubjectFull: Medical databases Type: general – SubjectFull: Chlorpromazine Type: general – SubjectFull: Ketorolac Type: general – SubjectFull: Disease relapse Type: general – SubjectFull: Metoclopramide Type: general – SubjectFull: Migraine Type: general – SubjectFull: Nerve block Type: general – SubjectFull: Dexamethasone Type: general – SubjectFull: Acetaminophen Type: general – SubjectFull: Adults Type: general – SubjectFull: United States Type: general Titles: – TitleFull: 2025 guideline update to acute treatment of migraine for adults in the emergency department: The American Headache Society evidence assessment of parenteral pharmacotherapies. Type: main BibRelationships: HasContributorRelationships: – PersonEntity: Name: NameFull: Robblee, Jennifer – PersonEntity: Name: NameFull: Minen, Mia T. – PersonEntity: Name: NameFull: Friedman, Benjamin W. – PersonEntity: Name: NameFull: Cortel‐LeBlanc, Miguel A. – PersonEntity: Name: NameFull: Cortel‐LeBlanc, Achelle – PersonEntity: Name: NameFull: Orr, Serena L. IsPartOfRelationships: – BibEntity: Dates: – D: 01 M: 01 Text: Jan2026 Type: published Y: 2026 Identifiers: – Type: issn-print Value: 00178748 Numbering: – Type: volume Value: 66 – Type: issue Value: 1 Titles: – TitleFull: Headache: The Journal of Head & Face Pain Type: main |
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