Updated ER Migraine Guidelines Provide Clear Direction for Clinicians

A recent publication in Headache: The Journal of Head and Face Pain, “2025 Guideline Update to Acute Treatment of Migraine for Adults in the Emergency Department: The American Headache Society Evidence Assessment of Parenteral Pharmacotherapies,” provides updated guidance for treating migraine in emergency settings. In February 2025, the American Academy of Neurology (AAN) Quality Committee reviewed the guideline and voted to affirm its value through the organization’s formal Affirmation of Value process. As a result, the guideline will be linked within the AAN’s guidelines section, recognizing it as an important clinical resource for neurologists.

The guideline focuses on parenteral treatments for adults who come to emergency rooms with migraine. Emergency visits for headaches are common, yet treatment approaches can vary across institutions. These new guidelines give clinicians clear direction to make more consistent, informed decisions in fast-paced emergency settings.

Jennifer Robblee, MD, MS, explained the reasoning behind the update in a recent interview. “We know that headache, particularly migraine, still leads to patients going to the emergency room way too often,” she said. “Over a third of them aren't getting headache freedom. There's still massive variability in how we treat patients.” The new guidelines aim to address this variability and support more consistent headache treatment across the country.

The 2025 update builds on AHS’ previous recommendations by incorporating the latest research on parenteral therapies for migraine. It gives clinicians guidance on which treatments to use and which to avoid, helping ensure patients receive reliable, up-to-date care in the emergency department.

The guidelines also address inconsistencies in emergency care and incorporate new evidence that has emerged since the last guideline. “The big take-home message is we now have two Level A recommendations,” Dr. Robblee noted. “And Level A recommendations here mean that you must offer. So, this is pretty bold language. And in the 2016 guideline, there were no Level A recommendations.” The new recommendations reflect stronger evidence supporting specific treatment approaches.

Two treatments, IV prochlorperazine and greater occipital nerve blocks, now carry Level A recommendations, meaning clinicians should offer them to patients when appropriate. Level A represents the strongest level of evidence in the guideline framework. At the same time, the guideline strengthens recommendations against certain opioid therapies. Hydromorphone, in particular, is now a Level A “must not offer” treatment because safer and more effective options exist for managing migraine.

These new guidelines give clinicians clearer direction for treating acute migraine in emergency settings. The AAN’s affirmation of value further recognizes the recommendations as an important resource for neurologists.

Watch the full interview with Dr. Robblee: 

Video Transcript

Dr. Rashmi Halker Singh:

I'm Dr. Rashmi Halker Singh. I'm the deputy editor of Headache. It's my absolute pleasure today to be joined by Dr. Jennifer Robblee, who's the first author of the 2025 Guideline Update to Acute Treatment of Migraine for Adults in the ER, the American Headache Society Evidence Assessment of Peritoral Pharmacotherapies. Welcome, Dr. Robblee. I'm so excited to speak to you about this.

Dr. Jennifer Robblee:

Thank you so much for having me here. I'm really excited to be speaking about it.

Dr. Rashmi Halker Singh:

So first of all, can you share with our audience what prompted AHS to update the ER treatment guidelines for 2025 and what problems were you all hoping to address?

Dr. Jennifer Robblee:

I mean, first off, we know that headache, particularly migraine, still leads to patients going to the emergency room way too often. There's about 3.5 million headache visits a year, and at least a quarter of those, probably more, are migraine. Over a third of them aren't getting headache freedom. There's still massive variability in how we treat patients. I mean, most of the time they come back and tell me, "I had a migraine cocktail. Do you know what was in it? " Medication. Good to know. We still know that opioids are getting used. The rate of how often they're getting used has at least decreased, but they are still getting used as a first line treatment or pretty early in the selection treatment. So there's still lots of room to move. Plus, we knew there was a lot of new studies. We know that there is now a lot of data on nerve blocks, which had not been looked at into the 2016 study.

So lots of things that we could really address and try to update. The other impetus was that the guideline committee likes to have their guidelines updated every five years and we're past that five-year date, so it was time to do it.

Dr. Rashmi Halker Singh:

Well, I was able to resonate with many of the comments you shared actually just from conversations I've had with patients today. So that's

Dr. Jennifer Robblee:

Exactly. 

Dr. Rashmi Halker Singh:

Yeah, absolutely. Very common. So for clinicians who haven't reviewed these guidelines just yet, can you walk us through what are the most significant changes from prior guidelines?

Dr. Jennifer Robblee:

Yeah. So the big take home message is we now have two level A recommendations. And level A recommendations here mean that you must offer. So this is pretty bold language. And in the 2016 guideline, there were no level A recommendations. So we're at work, really hitting it hard and we've come with two. 

So the first one is IV prochlorperazine. So that is a must offer, of course, with the caveat that it should be a patient who it's appropriate. You're not worried about any major contraindications. You don't think there's a high risk of them having tardive dyskinesia, extrapyramidal symptoms and whatnot. The other one that now also has level A for recommendation is greater occipital nerve blocks. And again, with the caveat that you want to choose it for the appropriate patient and the patient needs to be comfortable with the fact that they're going to get injections in their head, but these are now both options that must be offered to patients.

So that's a really exciting update. Prochloroparazine was in the 2016 guidelines, but it was a level B. So it's now been upgraded to a level A. And the inclusion of greater occipital nerve blocks, that's completely brand new. 

The other big update is that before opioids were in the guideline and the recommendation was to not offer them, but it's now been, I guess you would say, downgraded to a level A must not offer specifically for hydromorphone. And that's because of a study that was a grade one study that had been done since the 2016 guideline, where hydromorphone and prochlorperazine were compared. And prochlorperazine very clearly beat out hydromorphone and adding in that we know that hydromorphone and other opioids come with significant risks, including ongoing use can increase medication overuse. We know that there's higher risk of addiction. And we know that just in general, patients don't tend to do as well. They're more likely to come back and need more treatment, not achieve headache freedom. 

And so we are able to say that we really shouldn't be offering this. Obviously, this is not, as someone recently said to me, a “God-line”. I really liked that line, so I'm stealing it. There are going to be cases where it could be appropriate. And we did put the caveat that there may be appropriate patients, but it should be someone where you're not worried about addiction, not worried about medication, overuse headache. They're not on really high amounts of opioids where you're worried about causing overdose or side effects. They've previously had opioids and you know that they have a good response with good tolerability. So again, it needs to be done very thoughtfully if you are going to use them.

Dr. Rashmi Halker Singh:

So those are a lot of big changes that you've just outlined. I think it's been very helpful for the treating clinician and also very patient focused as well. And I think we'll hopefully allow the clinician to have conversations with patients about why these changes are important and hopefully allow them the best possible care. 

I want to switch the topic a little bit because we know that patients with migraine go to the ER for a different reason. Sometimes it might be an attack that just has not responded to what they have at home. Sometimes it might be an attack that's been going on for a couple of days. Sometimes it might be a definition for status migrainosus. Sometimes it might be a recurrent attack and sometimes it might be a refractory migraine. Do the guidelines address these different scenarios a little bit? And can you speak to that in a little bit more detail as well?

Dr. Jennifer Robblee:

Yeah. Unfortunately, they don't speak to it as much as I wish they did because these are some of the things I hold near and dear to my heart, status migrainosus, refractory migraine. Those are my babies. And I think what's important to know is that the studies that we're looking at, the majority of them were done in the emergency room, but even some of the studies included if they were parenteral treatments, they were allowed to have been done on an outpatient basis. 

So first off, some of the studies actually got downgraded in terms of how we did our recommendation if the population studied wasn't representative of the emergency room. So that's part one where really our focus was headache being treated in the emergency room where it was diagnosed as migraine. That might include patients who had any of the possibilities that you just mentioned, but none of the studies were specifically focused on those populations.

For instance, we don't have a randomized control trial for a status migrainosus. So while you can use these to apply to status migrainosus, it's with the knowledge that the guidelines are for a migraine attack in general where they've ended up in the emergency room, but not specifically for status migrainosus, even though I'm sure some of the studies did include those patients. 

Refractory migraine, we really don't have great data on what to do for them acutely, and less likely that any of them were really included in these studies, but it's always possible. But in terms of recurrent attacks and an attack that didn't respond to something at home, my guess is that was a good portion of the patients, but that data was often not well captured. And of interest, a lot of these studies don't actually tell us how long the attacks have been going on by the time patients were seen.

Often they don't include data about what they've already used or treated at home. So did they use all of their home treatments and it didn't work or is it someone who they don't have any good home treatments? And this is really what they're getting first for an attack that was particularly bad. So there's a lot more that we could do in these studies in the future to really try to capture who specifically is the population being studied. So a lot of that stuff is less well known than we'd like.

Dr. Rashmi Halker Singh:

I think that's very, very helpful. Do you anticipate any barriers that ER teams might face as they try to implement these guidelines and how can we help overcome any of those challenges?

Dr. Jennifer Robblee:

Yeah. I think in headache, we are very good about getting good quality studies. We have great consensus statements and guidelines out there. One thing that we don't tend to do a lot of is implementation science, and there's actually a lot that could be done there, but it's a really complex field. Our default is to say that we need to make sure that they're trained. And that might be true for some of the physicians and the APPs in the emergency room where perhaps they don't know how to do an occipital nerve block. But they're often doing a lot of nerve blocks and they're very comfortable with procedures and that's likely not the only barrier that's missing. 

So when you look at implementation science, there's actually a whole, I guess you could call it a whole strategy or a whole approach that people use called ERIC, and it's got 73 different strategies in different clusters. And it looks at everything from not just how you educate, but also, do you have the right stakeholders? Have you identified champions and headache and an emergency med who can really help guide and promote this change? Have you involved patients and their families? Do they want this procedure? Are they increasing that demand? Have you gotten the media involved? Have you gotten advocacy groups involved? How is the infrastructure going to change? Do emergency room doctors have enough time to feel like they can do this procedure as opposed to just quickly put it in order for prochlorperazine? Are they getting reimbursed enough that it's worth their time? Are insurance companies going to cover this? So there's so many different aspects that we need to really address to help make sure that our guidelines really bring science to the bedside.

Dr. Rashmi Halker Singh:

As we think about the most important people in the room, our patients, how do you hope that these guidelines will change or hopefully improve their experience the next time a patient goes to the ER with a migraine attack?

Dr. Jennifer Robblee:

The most important thing in my mind is that we're really inconsistent with what patients get. And I would love to see, especially for a patient where they're naive to treatments and we don't know what works for them, but they're offered the things that we at least have the best evidence available. So if a patient comes in with a migraine attack, they've never been treated with anything in the emergency room or they're not sure what they've had in the past, that they're then offered something that we have level A. So either they're given prochlorperazine or greater occipital nerve blocks as the potential next step. Now, whether or not you start to add in some other options and do combined therapy, that's a whole area that we need more research. But for instance, from the 2016 guidelines, we know that there's level B evidence for using dexamethasone to prevent recurrence of the migraine attack.

So perhaps that might be something that would get added into the mix. Would you bring in some of the other level B medications like some of the NSAIDs like ketorolac, for instance, and add that into the mix? We now also have level B evidence for superorbital nerve blocks. Let's say they've got a lot of frontal pain. Do we want to add that on top of the greater occipital nerve block? 

So considerations like that, but doing it thoughtfully with the science to back it up and help guide why we're selecting these treatments. And then also veering away from saying that the patient got a migraine cocktail. That doesn't tell me what the patient got. It doesn't tell me what I should do in the future. I really want to know the patient got this level A treatment combined with perhaps this level B treatment or they didn't get this level A treatment, but it's because they tried it in the past and didn't respond. Or I felt that they were at high risk of having a side effect because they're already on a daily neuroleptic. And so I didn't want to add that on top of it. 

So having that sort of thoughtful decision and ultimately hoping that we can try to build our EMRs so that there's even these sort of flows to how you would make these decisions to help clinicians when they're busy and they need that touch of the finger help. So that's what I'd love to see is this more consistent medicine offered to patients because that's going to hopefully lead to better quality of care and hence better results for them, more headache freedom, less likely to be bouncing back to the emergency room.

Dr. Rashmi Halker Singh:

I love their vision. Well, you've shared that these guidelines are updated every few years. You and your team have been able to address some of the gaps of the last iteration of these guidelines. As you look forward, what are some of the remaining gaps that you hope that the next iteration of these ER guidelines will hopefully address?

Dr. Jennifer Robblee:

I think that's a really great question. I'll kind of give a couple different answers. So part one is I want us to do a better job of how we do the studies in the emergency room. I want future studies to have better sample sizes. Unfortunately, the tools that we used that were used in the 2016 study, it doesn't actually downgrade a study for low sample size or for not being the optimal population or for not using the optimal time point. So I think we need to start to set expectations of if you're doing a study on migraine in the emergency room, just like we have guidelines for how you do an acute treatment trial, just like you have guidelines for how you do a preventive treatment trial. Here's how you should do a treatment trial in the emergency room for migraine. We need to have consistent endpoints. What people chose to use as the endpoint was all over the map. 

I think we need to use something standardized, especially for parenteral treatments like one hour, which is something that's mentioned in the acute guidelines, where two hours is the typical endpoint, but one hour was mentioned as a consideration for parental treatments. I think that would be a more appropriate standard. And making sure that we've chosen what should be looked at what hour. Is it the change in headache and what is the rating scale that we're using? And are we looking at headache freedom, headache relief? Are we looking at most bothersome symptoms because that's almost never captured in these? And is it relevant in this patient population? We don't even know that. 

So that's one part is we need to have better consistent data and better baseline data needs to be picked up. Is this a patient who has chronic or episodic migraine? How long was this attack? Often it's just time from treatment to response, but did they come in two hours into their headache? Did they come in two days, two weeks? That's really relevant data because then we can also start to address things like status migrainosus. So all of that stuff needs to be mentioned as well as what did they actually take at home? Is this a patient who is not responding to home treatment or is this an untreated or incompletely treated attack? Those are also really important differences for which patient we're studying. 

The next piece is that combination treatment I talked about. Iis using prochlorperazine good enough or should it be prochlorperazine plus dexamethasone plus ketorolac? How do we actually start to build what we classically talked about as this migraine cocktail? What is that combo infusion that is optimal? So I think we need to start to have better studies around that. 

And then the final piece I alluded to in part one is, I'd really like us to study status migrainosus. Obviously that's a huge bias for me, but I think we also need new standards of what the expectation there is because how do you study a patient who often contact me that same day or the next day when their treatments haven't worked and to enroll them, we'd have to say, "Well, we got to wait till you've been 72 hours." And so right now we don't have a good way to study these patients unless you're just kind of catching them untreated several days in. So we need to come up with a plan of how we study these patients so we can actually start to have some randomized control trials on how to treat specifically these patients. Because likely a huge proportion of the people in the emergency room are patients with status migrainosus.

But as I mentioned in part two, we don't know that because that data is not captured and we don't have any studies on that specific group. And I mean, obviously, I can go and list a million other dreams, but I think those are good three dreams right now, right?

Dr. Rashmi Halker Singh:

Oh yeah, absolutely. And hopefully by the time we're ready to update these again, we'll have the trials we need to answer those really important questions.

Dr. Jennifer Robblee:

Fingers crossed.

Dr. Rashmi Halker Singh:

Yeah. Well, thank you so much for taking the time to speak with me today and thank you and your co-authors for the immense work you put into creating these guidelines, which will help so many people who live with migraine every single day.

Dr. Jennifer Robblee:

Thank you very much. It was definitely a labor of love and I know we were all very relieved to get it done and very pleased that we have this to offer to the community and our patients to help guide treatment.