If known, treat specific<unk>  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<unk>  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<unk> s
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 migraine 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<unk> loperidol 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 migraine, cluster<unk> , occipital neuralgia, cervicogenic<unk> , or migraine with occipital nerve irritation or tenderness 
Severe, intractable status migrainosus 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 migraine, cluster<unk> , occipital neuralgia, cervicogenic<unk> , or migraine 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
Headache
Migraine headache
Tinnitus
Tension headache
Dizziness
Cluster headache
Sore throat
Meningitis/encephalitis