1st line: Prochlorperazine (compazine) 10mg IV (+/- diphenhydramine 12.5mg IV)
Most effective therapy
2nd line:
Metoclopramide (reglan) 10mg IV
DHE 1mg IV over 3min
Consider metoclopramide or prochlorperazine as pre-treatment antiemetic
Contraindications: pregnancy, cardiovascular disease, hypertension
Triptans
Contraindications: cardiovascular disease, use of DHE in previous 24hrs
Ketorolac
Steroids
Consider dexamethasone 10mg IV x 1 to prevent recurrence 48-72 hrs post-ED discharge, if history of recurrent headaches (NNT = 10)
Most effective therapy
Metoclopramide (reglan) 10mg IV
DHE 1mg IV over 3min
Consider metoclopramide or prochlorperazine as pre-treatment antiemetic
Contraindications: pregnancy, cardiovascular disease, hypertension
Triptans
Contraindications: cardiovascular disease, use of DHE in previous 24hrs
Consider metoclopramide or prochlorperazine as pre-treatment antiemetic
Contraindications: pregnancy, cardiovascular disease, hypertension
Contraindications: cardiovascular disease, use of DHE in previous 24hrs
Consider dexamethasone 10mg IV x 1 to prevent recurrence 48-72 hrs post-ED discharge, if history of recurrent headaches (NNT = 10)
If known, treat specific headache type; avoid opioid medications if at all possible
1st line: prochlorperazine (compazine) 10 mg IV (+/- diphenhydramine 25-50 mg IV) + 1 L IVF bolus
Place prochlorperazine in IV bag to reduce chances of side effects from rapid administration
Alternative metoclopramide 10 mg IV (diphenhydramine addition shows no clinical benifit)
Acetaminophen IV or PO, 325-1000 mg
Ketorolac 10-30 mg IV (30-60mg IM)
Lower doses are shown to be just as effective
Sumatriptan most effective within 6 hours of headache onset
Serotonin 5HT1B/1D receptor agonist (e.g. sumatriptan)
6 mg SQ or IM, may repeat dose x1 after 1 hour, max 12 mg / 24 hours
OR 100 mg PO, may repeat dose x1 after 2 hours, max 200 mg / 24 hours
OR 1-2 sprays IN (may repeat after 2 hours)
Contraindications to triptans include CV disease, uncontrolled HTN, pregnancy
Consider dexamethasone 10 mg IV single dose to prevent recurrence 48-72 hrs post-ED discharge, if history of recurrent headaches
Place prochlorperazine in IV bag to reduce chances of side effects from rapid administration
Alternative metoclopramide 10 mg IV (diphenhydramine addition shows no clinical benifit)
Lower doses are shown to be just as effective
Serotonin 5HT1B/1D receptor agonist (e.g. sumatriptan)
6 mg SQ or IM, may repeat dose x1 after 1 hour, max 12 mg / 24 hours
OR 100 mg PO, may repeat dose x1 after 2 hours, max 200 mg / 24 hours
OR 1-2 sprays IN (may repeat after 2 hours)
Contraindications to triptans include CV disease, uncontrolled HTN, pregnancy
Magnesium 1-2 g IV over 30-60 minutes, low side effect profile, in treatment of acute<unk>  attacks
Valproate sodium 500-1000 mg IV in 50 mL of NS over 20 minutes (alternatively 10 mg/kg IV, pediatrics, max 500 mg)
Droperidol IV/IM 1.25-2.75 mg, plus or minus diphenhydramine for extrapyramidal symptoms
Perform EKG monitoring for patients at risk of QTc prolongation
Do not give to patients who take already multiple QT prolonging drugs
Consider haloperidol IV 5 mg in IVF bolus with diphenhydramine to prevent need for rescue medications
Consider 5-10 mg PO olanzapine (Zyprexa, Zydis) for prochlorperazine allergy
Particularly useful in psych patients with mania, BPD, psychosis
IV olanzapine may be as safe or safer than IM, with faster onset
Ketamine IM/IV at subdissociative dosages, with risk stratification for potential ICP increase, though now widely considered a myth
Cervical spine injection with IM injection of 1.5 mL of 0.5% bupivacaine (plus or minus methylprednisolone acetate) bilaterally to the sixth or seventh spinous process
Sphenopalatine ganglion block
Great for patients without an IV
10 cm cotton-tipped applicator soaked in lidocaine or bupivicaine and inserted nasally along the superior border of the middle turbinate and left for 5-10 minutes 
Consider greater occipital nerve block
For refractory occipital<unk> , cluster headache, occipital neuralgia, cervicogenic headache, or<unk>  with occipital nerve irritation or tenderness 
Severe, intractable status<unk> sus may benefit from off-label IV propofol
Requires procedural sedation monitoring and possible IV fluid resuscitation, respiratory decompensation intervention
Propofol 0.5 mg/kg bolus, then 0.25 mg/kg every 10 minutes for 1 hour
Less aggressive regimens include propofol 10 mg q5-10 min to ma of 80 mg
Consider using 1 mL 2% lidocaine added to every 10 mL of 10 mg/mL concentration propofol
Average dosage required ~100-125 mg
Perform EKG monitoring for patients at risk of QTc prolongation
Do not give to patients who take already multiple QT prolonging drugs
Particularly useful in psych patients with mania, BPD, psychosis
IV olanzapine may be as safe or safer than IM, with faster onset
Great for patients without an IV
10 cm cotton-tipped applicator soaked in lidocaine or bupivicaine and inserted nasally along the superior border of the middle turbinate and left for 5-10 minutes 
For refractory occipital<unk> , cluster headache, occipital neuralgia, cervicogenic headache, or<unk>  with occipital nerve irritation or tenderness 
Requires procedural sedation monitoring and possible IV fluid resuscitation, respiratory decompensation intervention
Propofol 0.5 mg/kg bolus, then 0.25 mg/kg every 10 minutes for 1 hour
Less aggressive regimens include propofol 10 mg q5-10 min to ma of 80 mg
Consider using 1 mL 2% lidocaine added to every 10 mL of 10 mg/mL concentration propofol
Average dosage required ~100-125 mg
Typically not the role or responsibility of the EP
Lifestyle changes (avoiding caffeine, smoking and food triggers)
If inclined to give Rx, give very short supply and ensure proper follow up
Consider drug side effects, interactions, cormorbidities
American Academy of Neurology and American Headache Society level A drug options, starting dosages
Valproate/divalproex 250 mg q12
Metoprolol 25 mg q12
Propranolol 30 mg q8
Timolol 10 mg q12
Topiramate 25 mg QHS x1, then 25 mg q12
Valproate/divalproex 250 mg q12
Metoprolol 25 mg q12
Propranolol 30 mg q8
Timolol 10 mg q12
Topiramate 25 mg QHS x1, then 25 mg q12
Migraine headache
Tension headache
Cluster headache
Postpartum headache
Meningitis/encephalitis
Post-lumbar puncture headache
Neoplastic meningitis
Benign paroxysmal positional vertigo