Should you go to A+E for Migraine?

This can be a difficult decision to make, and you may have to weigh up the pros and cons in the midst of an unpleasant attack. It is, however, something to consider as part of a rescue plan, should the need arise.

A good initial approach might be to contact NHS Direct 111 to discuss your symptoms and for further support before attending A+E.

For many, the thought of being in the A&E department during a migraine attack is dreadful. Many people who have attended for migraine in the past will know that it is not generally a migraine-friendly place. The excessive lights, noise, smells, disruptions, anxiety, lengthy wait times and very little control of the environment, can be unbearable.

The triage system in place at A&E will prioritise those with life-threatening conditions, resulting in potentially longer wait times and during a severe attack, you might struggle to fully answer the many questions you will be asked. Here it could be helpful to have someone with you.

Nevertheless, there will be times when an A&E visit is appropriate and should not be avoided.

Times when you might have to attend A&E

This is not an exhaustive list but here we consider some reasons you should attend:

• If you are experiencing new severe and debilitating symptoms that cannot be reviewed or managed by the GP or NHS 111
• If your symptoms are severe and are not manageable at home
• If the headache starts suddenly like a ‘thunderclap’ reaching maximum severity over seconds or minutes
• If you are having a continuous attack that won’t stop with your usual treatments and you need to break the cycle
• If you are vomiting for some time and at risk of dehydration
• If you have a sudden onset headache that is unlike your usual migraine, especially if you are over age 50
• If you experience symptoms such as neck stiffness, a fever or seizures (which can be associated with meningitis) or stroke-like symptoms which may include muscle weakness, tingling, numbness, confusion, speech difficulty.

People who have the rare types of migraine, hemiplegic migraine (HM) or migraine with brainstem aura, will experience some symptoms that resemble a stroke:

If you are diagnosed with Hemiplegic Migraine or Migraine with brain stem aura and you can experience stroke-like symptoms such as temporary weakness on one side of the body, changes in speech and vision, tingling, numbness and thinking difficulties with your attacks; you should discuss a rescue plan with your doctor or specialist, including when to seek urgent medical help. You will want to avoid unnecessary tests if you recognise such attacks, but equally do not want to miss something more serious and a discussion with your doctor can help you decide.

Overall, you should seek urgent medical help for an attack that concerns you and this will likely be with your GP or NHS 111 in the first instance. These may be occasions when you want to make sure there isn’t something more serious happening because the attack seems different in some way.

What can you expect in the A&E department?

There isn’t a single standard rescue treatment available across all A&E departments. The priority will be excluding any life-threatening causes such as an underlying bleed, stroke or severe infection.

For the severe migraine attack, the treatment offered will include medicines to relieve the pain, nausea/vomiting, and dehydration. You will be asked about what treatment you have already taken and dosages.

You will be offered options that can be given by injection to work quickly, and if you are experiencing nausea and vomiting, treatments by mouth is not an option. Fluids given directly into the vein (intravenous) will help overcome dehydration and lead to quicker relief.

You may be offered:

Triptans – such as by injection or a nasal spray

Intravenous anti-inflammatory or NSAID such as diclofenac, ketoprofen, aspirin.

Anti-nausea medicines such as injections of prochlorperazine, metoclopramide, ondansetron

Fluids for re-hydration

What next?

Your GP should review your symptoms and consider the most appropriate next steps including acute and preventive medications. Being aware of trigger factors and managing these where possible could also minimise the severity of attacks.

If treatments tried with your GP has been inadequate or ineffective a referral to a neurologist or headache specialist might be the next step. Specialists can provide a full review of your symptoms and access to a wider range of treatments.

You might explore whether a newer targeted migraine treatment might be more effective and better tolerated. Discussing the most suitable acute and preventive treatments for you and making a rescue plan for severe and difficult attacks, could be invaluable and help to avoid future A&E visits for migraine.