How Are Migraines Treated the ER?

Medication Cocktail for Migraines and Severe Headaches in an Emergency

Every 10 seconds, someone in the United States develops a migraine headache so severe they go to the hospital emergency room (ER). Given the pain and risks associated with these episodes (e.g., uncontrolled vomiting), ER doctors often opt for migraine treatments that can be administered via injection or IV to have a quick effect.

Emergency treatment for migraine depends on a patient's specific symptoms and overall health and health history. The ER typically administers a combination of medications. The migraine cocktail includes a mix of non-steroidal anti-inflammatory drugs (NSAIDs), magnesium, triptans, and IV fluids. 

This article provides an overview of emergency treatments for migraines and headaches, including migraine cocktails and other approaches used in the ER. Individual care may differ slightly from these standard protocols.

Patient looking at the window with hope in the hospital
Sorrasak Jar Tinyo / Getty Images

When to Seek Care

If you deal with migraines, it's helpful to know that there are solutions if they ever get so bad as to warrant emergency care. But knowing when to seek that level of medical attention is important.

If you would describe your pain as your worst migraine attack (or headache) ever, cal 911.

Concerning Symptoms

If your headache is accompanied by any of the following, a trip to the hospital is recommended, according to the NHF:

  • Vision loss
  • Uncontrollable vomiting
  • Head pain that lasts more than 72 hours with fewer than four solid hours of relief
  • Symptoms that are unusual for you or frightening
  • Loss of consciousness

Treatment Approaches in the ER

The treatment you might receive in a hospital emergency department for a migraine headache will be based, for the most part, on your symptoms and personal health history. In other words, there's no one-size-fits-all migraine cocktail.

However, there are standards and recommendations. For one thing, medications given in the ER for migraine headaches are typically administered parenterally—in some way other than by mouth, including by subcutaneous injection (a shot just under the skin), intramuscularly (a deeper injection into the muscle tissue), and intravenously (via an IV tube).

These methods allow medications to work more quickly in the body, and they are more effective for someone who's experiencing so much nausea and/or vomiting that keeping down a pill is almost impossible. Many people are also given fluids via IV to prevent dehydration.

In 2016, the American Headache Society (AHS) put together a panel of experts to review clinical trials of the many diverse medications used in emergency settings to treat migraines in adults to determine which truly work best and are safest. The panel considered studies of 28 different medications to come up with recommendations for the acute treatment of migraines in adults.

First-Line Treatments

Based on the results of 68 clinical trials, the AHS panel determined that adults who visit the ER for migraine pain and other symptoms should be offered one or more of these three medications to treat pain and other symptoms, particularly nausea and vomiting:

  • Metoclopramide, an antiemetic (anti-nausea) medication that blocks dopamine receptors in the brain to relieve nausea and vomiting as well as pain
  • Prochlorperazine, an anti-psychotic
  • Sumatriptan, a selective serotonin receptor agonist (SSRI) that constricts blood vessels in the brain and blocks certain substances that cause pain to relieve headache, nausea, and other migraine symptoms

The panel also determined that adults with migraine should receive a dose of dexamethasone, a steroid that lowers the risk that a migraine will recur.

In March 2023, the Food and Drug Administration (FDA) approved Zavzpret (zavegepant) for the treatment of acute migraines with or without aura. Zavzpret is the first calcitonin gene-related peptide (CGRP) receptor antagonist administered as a nasal spray.

Second-Line Treatments

If for some reason the first-line medications are not appropriate, the panel found that the following alternatives may be offered in a migraine cocktail:

  • Acetaminophen, an analgesic
  • Acetylsalicylic acid, aspirin
  • Chlorpromazine, an anti-psychotic
  • Ketoprofen, a nonsteroidal anti-inflammatory drug (NSAID)
  • Diclofenac, an NSAID
  • Droperidol, an anti-dopamine drug that relieves nausea
  • Haloperidol, an anti-psychotic
  • Ketorolac, an NSAID
  • Valproate, an anti-convulsant that doesn't relieve migraines but may help to prevent a recurrence of one

Medications That Are Not Recommended

Among medications that have commonly been used in the ER to treat migraine headaches are a handful that the panel suggests should not be given because they don't work as well as others or for other reasons. Hydromorphone and morphine, for example, are opioids—a class of drug associated with addiction.

On the AHS list of drugs that are best avoided for treating migraine in the ER are:

  • Diphenhydramine, an antihistamine
  • Hydromorphone, an opioid
  • Lidocaine, an analgesic
  • Morphine, an opioid
  • Octreotide, a medication often given to cancer patients to control diarrhea

Caution for Pregnant Women

Some medications used in the emergency treatment of migraine headaches are known to cross the placenta of women who are expecting and cause possible harm to a developing baby. These include:

  • NSAIDs: These are not considered safe for pregnant women, as these drugs can interfere with the healthy development of a baby's lungs, cause low levels of amniotic fluid, or slow or stop labor during childbirth.
  • Dihydroergotamine: Also known as an ergot alkaloid, this drug is on a long list of medications cited by the AHS panel as having too little available information to recommend or not recommend for pregnant women. Brand names in this class include D.H.E. 45 and Migranal.
  • Opioids: Both oxycodone and morphine are opioid medications that carry a high risk of abuse and addiction. Studies have shown that opioids are also less effective at terminating migraines than the antiemetic, metoclopramide.
  • Valproate: This anti-seizure drug is sometimes ordered to prevent recurrent migraines. Valproate is considered highly teratogenic, and is banned in many countries for use in pregnant women and women of childbearing age.

A Word From Verywell

Treating a migraine headache that's severe enough to require emergency care can be tricky. Many medications have been used to relieve pain, nausea, vomiting, and other symptoms—some more successfully than others. And despite the AHS recommendations of the most effective and safest protocols for managing an acute migraine in an emergency setting, the treatment a patient receives in one hospital ER may differ from that offered by another.

The most important thing to remember if you go to the ER for migraine (or any other emergency) is that you need to be an advocate for yourself or make sure someone is with you who can fill that role. This means being forthright and thorough when answering questions about your current health and any medications you take, including over-the-counter products, supplements, and recreational drugs. Your honesty will help the doctors caring for you hone in on the migraine medications most likely to relieve your pain as quickly as possible.

Frequently Asked Questions

  • Can you go to the ER for a severe migraine?

    Yes, you can go to the ER for treatment of a migraine. However, it isn’t necessary unless it is a severe migraine or associated with the following symptoms: 

    • Confusion
    • Fever
    • Numbness
    • Stiff neck
    • Weakness
    • Vision changes

    Seek immediate medical attention for a headache that comes on suddenly and reaches maximum intensity within a few minutes.

  • What is a migraine cocktail at the hospital?

    A migraine cocktail is a combination of medications used to treat migraine in the ER. This can include an NSAID, dihydroergotamine, anti-nausea medication, an antihistamine, magnesium, and fluids. The exact combination of medications will vary from person to person.

  • Can I make a migraine cocktail at home?

    Yes, a common at-home migraine cocktail includes 250 mg of aspirin, 250 mg of Tylenol (acetaminophen), and 65 mg of caffeine. These are also the ingredients in Excedrin. Research shows most migraines respond to this drug combination within two hours.

6 Sources
Verywell Health uses only high-quality sources, including peer-reviewed studies, to support the facts within our articles. Read our editorial process to learn more about how we fact-check and keep our content accurate, reliable, and trustworthy.
  1. Migraine Research Foundation. Migraine facts.

  2. Dodson H, Bhula J, Eriksson S, Nguyen K. Migraine treatment in the emergency department: alternatives to opioids and their effectiveness in relieving migraines and reducing treatment timesCureus. 2018;10(4):e2439. doi:10.7759/cureus.2439

  3. Andrade C. Valproate in pregnancy: recent research and regulatory responsesJ Clin Psychiatry. 2018;79(3):18f12351. doi:10.4088/JCP.18f12351

  4. American Migraine Foundation. Understanding migraine treatment in the emergency room.

  5. American Migraine Foundation. Migraine cocktails: what they are and why they are misunderstood.

  6. Diener HC, Gaul C, Lehmacher W, Weiser T. Aspirin, paracetamol (acetaminophen) and caffeine for the treatment of acute migraine attacks: A systemic review and meta-analysis of randomized placebo-controlled trials. Eur J Neurol. 2022;29(1):350–7. doi:10.1111/ene.15103

Additional Reading

By Colleen Doherty, MD
 Colleen Doherty, MD, is a board-certified internist living with multiple sclerosis.