Acute headaches are a common and debilitating health issue for patients in the emergency department, often presenting a diagnostic challenge for clinicians. Evidence-based clinical guidance is beneficial not only for achieving symptom relief but also for identifying potentially life-threatening causes of the headache.
Today, we are taking a look at the recently released American Headache Society (AHS) guideline, Acute Treatment of Migraine for Adults in the Emergency Department, and comparing it to the 2019 American College of Emergency Physicians (ACEP) guideline, Critical Issues in the Evaluation and Management of Adult Patients Presenting to the Emergency Department with Acute Headache.
Guidelines for Comparison
| Acute Treatment of Migraine for Adults in the Emergency Department | Critical Issues in the Evaluation and Management of Adult Patients Presenting to the Emergency Department with Acute Headache | |
|---|---|---|
| Authoring Organization: | American Headache Society | American College of Emergency Physicians |
| Publication Date: | December 2025 | October 2019 |
| Links | Summary / Full Text | Summary / Full Text |
Key Similarities and Key Differences
Pain and Symptom Management:
The AHS guideline focuses on parenteral pharmacologic therapies. The ACEP guideline dedicates a section to pain management, discussing the preference of nonopioids to opioid medications. In the ACEP guideline, the recommendation to use nonopioid medications in the treatment of acute primary headaches is given the highest level of recommendation. This ACEP recommendation is the only recommendation in the guideline to be ranked that highly.
The AHS guideline similarly reflects that intravenous opioids are not recommended, clearly stating that the use of opioids for the treatment of migraine is discouraged. As previously mentioned, the AHS guideline focuses largely on pharmacological management, so it provides a wider scope of management options than the ACEP guideline touches on.
Risk Stratification and Imaging:
The AHS guideline is an assessment of parenteral pharmacotherapies. While the ACEP guideline also branches out to include discussion on risk stratification and imaging in two separate recommendations. The ACEP recommendations regarding risk stratification and imaging are outlined in the following table.
Comparison of Recommendations
| Topic | AHS | ACEP |
|---|---|---|
| Risk-stratification Strategies | Not addressed. | Use the Ottawa Subarachnoid Hemorrhage Rule ≥40 years, complaint of neck pain or stiffness, witnessed loss of consciousness, onset with exertion, thunderclap headache, and limited neck flexion on examination) as a decision rule that has high sensitivity to rule out subarachnoid hemorrhage, but low specificity to rule in subarachnoid hemorrhage, for patients presenting to the emergency department with a normal neurologic examination result and peak headache severity within one hour of onset of pain symptoms. |
| Pain/Symptom Management | Must offer for headache requiring parenteral therapy: Prochlorperazine IV, Greater Occipital Nerve Blocks Should offer for headache requiring parenteral therapy: Dexketoprofen IV, Ketorolac IV, Metoclopramide IV, Sumatriptan SC, Supraorbital Nerve Blocks May offer for headache requiring parenteral therapy: Acetylsalicylic acid IV, Chlorpromazine IV, Dexamethasone IV, Diclofenac IM, Dipyrone IV, Droperidol IM, Haloperidol IV, Valproate IV No recommendation: Caffeine IV, Dihydroergotamine IV/SC, Eptinezumab IV, Ergotamine SC, Granisetron IV, Ibuprofen IV, Ketamine IV, Lidocaine IV, Lysine clonixinate IV, Magnesium IV, Meperidine IV, Nalbuphine IV, Normal Saline IV, Paracetamol/Acetaminophen IV, Propofol IV, parenteral Promethazine, SPG Blocks, Tramadol IV, Trimethobenzamide IM May not offer: Diphenhydramine IV, Morphine IV, Octreotide SC/IV, Paracetamol/Acetaminophen IV Must not offer: Hydromorphone IV | Preferentially use nonopioid medications in the treatment of acute primary headaches in emergency department patients. |
| Imaging | Not addressed. | Use a normal noncontrast head CT (minimum third-generation scanner) performed within six hours of symptom onset in an emergency department headache patient with a normal neurologic examination, to rule out nontraumatic subarachnoid hemorrhage. Perform lumbar puncture or computed tomography angiography to safely rule out subarachnoid hemorrhage in the adult emergency department patient who is still considered to be at risk for subarachnoid hemorrhage after a negative noncontrast head CT result. Use shared decision making to select the best modality for each patient after weighing the potential for false-positive imaging and the pros and cons associated with lumbar puncture. |
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