Should you go to the emergency room (ER) if you have a migraine headache? Often, you can manage migraine attacks at home, and see your doctor later to talk about symptoms and treatment options.
But certain migraine symptoms are an alert to see your doctor or get emergency care right away. That’s because they could signal a more serious medical problem.
When to Get Emergency Care
Headaches are a common reason for people to seek emergency care, but it’s not always needed. Most people who go to the ER for migraine pain are just having a migraine attack, not a medical emergency.
There are some times, however, when it may make sense to go to the ER:
Your symptoms are worse than usual: Migraine symptoms that are new or seem more serious than normal can be signs that you need medical care right away. These symptoms may signal a life-threatening emergency, such as:
- A stroke
- A brain infection called meningitis
- An aneurysm, a bulging blood vessel in your brain that could burst and cause a type of stroke
Your symptoms come on faster than usual: Usually, migraine attacks gradually worsen over hours. You may notice changes in how you feel for days before the headache starts. But, if you have sudden, serious head pain, go to the ER. This is called a “thunderclap” headache, because you’re hit with a jolt of severe pain out of nowhere. It could be a sign of a stroke, not a migraine.
You have an “intractable” migraine: These severe migraines last for more than 72 hours (3 days) and don’t get better with medications you take when a migraine starts, such as triptans. Seek care at an ER or urgent care clinic for these painful attacks, which are also called status migrainosus.
Also go to the ER right away if you or a loved one have a new or severe headache with any of the following:
- High fever, stiff neck, numbness, muscle weakness, confusion, double vision, or vision loss
- Trouble walking or speaking clearly
- Loss of consciousness, or uncontrolled nausea or vomiting
- Extreme sensitivity to light and a sudden rash
- The head pain followed an injury or fall
- It gets worse if you cough or make a sudden movement
- You’re 50 or older
- You can’t stand even if you hold onto a chair or railing
- Your pupils are two different sizes
- One of your eyelids droops
If you lose the ability to talk when you have migraine attacks, get a medical ID bracelet or carry a card at all times that tells ER doctors and nurses about your diagnosis. If your loved one has this type of migraine, go with them to the hospital or explain it to emergency workers.
When to See Your Doctor Instead
Don’t go to the ER for frequent migraine attacks or a nagging headache that doesn’t get better with treatments, even if you’re fed up with the pain. Emergency doctors aren’t migraine specialists. Make an appointment with your doctor or neurologist instead.
Keep track of your regular or recurring headaches. Write down when they happen and what treatments do or don’t help. Share this info with your doctor.
If you’ve had migraines for years and notice changes in how they begin or in your symptoms, talk about it with your doctor. You may also want to see a headache specialist such as a neurologist, if you’re not doing so already.
At the ER: Tests You Will Have
If you’re headed to the ER with a serious headache, take a pillow, some dark glasses, and ear plugs to help you be more comfortable. Hospitals can be bright, noisy places.
Once you’re there, doctors and nurses will give you tests to check for any medical conditions that could be serious. They may also give you treatments to ease your pain and other symptoms.
ER doctors and nurses will examine you and do tests to see if migraine is the cause of your symptoms rather than some other health condition. Be sure to tell them about:
- All of your symptoms -- don’t downplay any of them or leave anything out
- Any new or different symptoms
- All medications and supplements you’ve taken in the last few days
- Any migraine treatments that have, until now, worked to relieve your pain
They'll give you an eye exam if you have any vision changes or problems. You may get a blood or urine test to rule out diabetes, infections, or thyroid problems that can cause headaches or other symptoms.
Emergency providers also may give you one or more of these tests to check for medical conditions that can cause serious head pain:
- CT scan: A set of detailed brain X-rays
- MRI scan: Magnetic fields and radio waves are used to produce detailed images of your brain and its blood vessels
- Spinal tap: A small sample of fluid from your spinal cord is tested to see if there’s any bleeding, or signs of a tumor or infection that may be causing your headache
Treatments in the ER
If your severe head pain is caused by migraine, an ER doctor will check your vital signs and may give you medicine through an IV to help you feel better. If needed, they may also give you IV fluid, containing water and salts, to hydrate you.
Some pain medications you may get at the ER as an IV treatment for migraine include:
- Nonsteroidal anti-inflammatory drugs (NSAIDs) such as ketorolac
- Corticosteroids such as dexamethasone (Decadron), which can prevent recurring migraines
If you have serious nausea or vomiting, a provider may give you:
- Sumatriptan, which you’ll get as an injection under your skin
- Anti-nausea drugs, also called antiemetics, such as chlorpromazine, metoclopramide (Reglan), prochlorperazine (Compro, Procomp), or ondansetron (Zofran)
Your ER doctor could also give you a nerve block to stop severe migraine pain. They’ll inject a small amount of numbing medication, such as lidocaine or bupivacaine, into the back of your neck at the bottom of your skull. This blocks pain signals from your nerves. Your pain should stop in a few minutes.
A nerve block can ease pain for a few weeks or months, but it’s not a long-term way to manage migraine pain. Nerve blocks are used only for severe pain relief when other treatments don’t work.
If you have an intractable migraine, or status migrainosus: Your ER doctor may give you a drug called dihydroergotamine (DHE-45) as an injection or through an IV, along with metoclopramide. They may also give you valproate in an IV. You may need to check into the hospital for a few days of these treatments.
Why you may not get opioids: Your ER doctor will probably not give you opioids for your pain. Opioids dull pain, but aren’t recommended for severe, acute migraine attacks. If you take opioids, you’re more likely to need another trip to the ER for head pain in a few days.
What Can You Expect After the ER?
Pain treatments for severe migraine that you get at the ER may not be long-lasting. You may still have some head pain that lingers. Once you go home, get complete rest for a day or two. This may help you prevent another painful attack.
When you’re back on your feet, make an appointment with your regular doctor or neurologist. They can help you create a plan to prevent severe migraines. They may prescribe a rescue drug you can take when you feel an attack coming on.
Your doctor will also go over your migraine triggers, so you can try to limit or avoid them to prevent headaches.