ER for a Migraine

Living with migraine means learning to manage a complex and often unpredictable disease. Most of the time, you are able to handle your attacks at home with your prescribed rescue plan. But sometimes, an attack can become so severe or present with such unusual symptoms that you are left wondering, "Is this something more? Do I need to go to the emergency room?" It’s a frightening and confusing position to be in. Making the decision to go to the ER is a significant one, and it’s important to feel confident and informed. This guide is here to offer gentle, clear guidance on when it is appropriate to seek emergency care for a migraine attack and what you can expect when you get there.

When Should You Go to the ER?

It is crucial to have a plan in place with your doctor about when to seek emergency care. However, there are some clear red-flag symptoms that should always prompt an immediate trip to the ER. These can be signs of a more serious underlying condition, like a stroke or meningitis, and it is always better to be safe.

Go to the ER if you experience:

The "Worst Headache of Your Life": If you experience a headache that is unusually severe and comes on with thunderclap intensity, this requires immediate attention.
A Headache with Fever and Stiff Neck: These can be signs of meningitis, a serious infection of the membranes surrounding the brain and spinal cord.
Neurological Symptoms You Have Never Had Before: This includes new or unusual weakness on one side of the body, vision loss, confusion, seizures, or difficulty speaking. While these can be symptoms of a migraine aura, they can also be signs of a stroke, and you cannot tell the difference at home.
A Headache After a Head Injury: Any headache that develops after a fall or a blow to the head should be evaluated immediately.
A Headache That Steadily Worsens over days and is accompanied by other neurological symptoms.

Consider the ER for an Unbreakable Migraine (Status Migrainosus)

Sometimes, you may need to go to the ER not because of new, alarming symptoms, but because you are in the midst of a severe, relentless migraine attack that has not responded to your home rescue plan. This is known as status migrainosus, a debilitating attack that lasts for more than 72 hours.

You might consider going to the ER if:

Your prescribed abortive medications have failed to provide any relief.
You are experiencing uncontrollable vomiting and are unable to keep down any fluids or medications, putting you at risk of severe dehydration.
The pain is so severe that you cannot function at all and feel you cannot safely manage it at home.

What to Expect at the ER

Going to the ER can be a stressful experience, especially when you are already in pain. Knowing what to expect can help.

Evaluation: The first priority of the ER team is to make sure your symptoms are not being caused by a life-threatening condition. They will likely perform a neurological exam and may order a CT scan or other imaging of your brain.
The "Migraine Cocktail": If other serious conditions are ruled out, the team will focus on breaking your migraine attack. They will likely administer a combination of medications intravenously (through an IV). This is often called a "migraine cocktail." While the exact components can vary, it typically includes:
IV Fluids: To treat the dehydration that is common with a severe attack.
An NSAID: A powerful anti-inflammatory like ketorolac.
A Dopamine Antagonist: A medication like prochlorperazine or metoclopramide, which is very effective for both migraine pain and nausea.
An Antihistamine: Often diphenhydramine (Benadryl), to prevent the side effect of restlessness (akathisia) that can be caused by the dopamine antagonist, and to provide sedation.
A Quiet Space: The ER team will do their best to provide you with a quiet, dark room where you can rest while the medications take effect.

How to Prepare for an ER Visit

It can be helpful to have a "go bag" ready with a few key items:

A list of all your current medications and allergies.
The name and phone number of your neurologist or primary care doctor.
Comfort items like an eye mask, earplugs, and a warm pair of socks.
Your insurance information.

A Final, Compassionate Thought

Trust your instincts. You are the expert on your own body and your own migraine patterns. If a headache feels different, more severe, or is accompanied by frightening new symptoms, do not hesitate to seek emergency care. It is always better to be cautious and to get the reassurance and treatment you need. There is no shame in needing a higher level of care to break a severe attack. It is a sign of strength to recognize when you need help and to advocate for your own safety and well-being.

Trusted Resources

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