Sometimes, a migraine attack escalates into an emergency. It's scary, and knowing what to do can feel impossible when you're in the thick of it. This post is designed to help you get the care you need. Remember: the faster you seek care, the faster you’ll address the attack and feel better. 

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Recognizing a Migraine Emergency

A migraine emergency is different from your typical attack. Key signs that indicate you need immediate medical attention include:

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• Intractable* pain or symptoms (status migrainosus):
  This is when you're past your breaking point. Your pain and symptoms are extreme prolonged pain, excruciating, or “in the red,” meaning you cannot move or function and you’ve had to stop everything that you’re doing, and this lasts for hours.
  
  
• New or unusual symptoms:
  Vision loss, confusion, weakness on one side, stiff neck, severe vomiting – these are NOT typical migraine symptoms and may be a sign of stroke or other serious conditions. If you suspect a stroke, remember to BE FAST (Balance, Eyes, Face, Arms, Speech, Time) and take time stamps.
  
  
• Your usual medications aren't working:
  If your rescue meds & devices offer no relief, you may need a different and more aggressive approach.
  
  
• You can’t stop throwing up:
  If you can’t stop throwing up, you need IV fluids.
  
  
• Worst headache of your life:
  Sudden, thunderclap pain that is unlike any migraine attack you've had before. One moment you were fine and the next you were in the worst pain imaginable.
   

If you’re experiencing any of these, go to the ER.

What to Take With You

Being prepared can make a significant difference in your ER visit. Pack a small emergency kit that includes:

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• A list of all medications you are currently taking (including over-the-counter drugs and supplements)
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• An emergency protocol from your headache specialist outlining the best recommended acute protocol, description of your migraine type, list of standard symptoms, list of medications and contraindications, including acute medications you’re reactive to (for example: “This patient doesn’t tolerate Reglan or Benadryl”). Include a preferred IV combination, with a backup option in case that hospital doesn't have the medications that work best for you.
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• Contact information for your primary care provider and headache specialist
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• Your insurance card and a form of ID
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• A medical history summary, including previous surgeries or other relevant conditions‍
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• A migraine diary will help the medical team understand your baseline and triggers.
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If you don’t maintain a regular migraine diary, jot down timestamps of your current attack’s symptoms, and what medications and treatments you used (with time stamps). If this attack exceeds 24 hours, include what day and time you took or used each treatment. This includes neuromodulation devices, over-the-counter meds & off-label solutions, etc.

If you can, prepare a comfort kit because you may be there for a while. This can include: 

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• Blanket or heated blanket
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• Socks
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• Tinted lenses or sunglasses
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• Airpods or headphones
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• Peppermint oil
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Dress comfortably but don’t wear your oldest pajamas. Sadly, migraine can be quite stigmatized and emergency room providers can be judgmental.

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Preparing for the ER

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Before you head to the hospital, or on your way there, try to call ahead to inform them that a patient with severe migraine symptoms is coming in. Alternatively, reach out to your headache specialist in advance, letting them know that you are going. Often someone from their team can reach out to the emergency department before you arrive. This likely will expedite your care.

Tips for Navigating Wait Times and Triage

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ER wait times can be long and unpredictable. And, while migraine is common, ER staff are not specialized in the condition like your headache specialist is. Here's how to make it more bearable and ensure your needs are heard:

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• Updates are your friend: Every so often, politely ask the triage nurse, "Is there an estimate on when I might be seen?". This keeps you in their mind without seeming demanding.
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• Communicate changes: If your pain worsens, you develop new symptoms, the vomiting won't stop, or you react to their treatment, tell a nurse immediately. Migraine attack symptoms can change rapidly, and staff need to know.
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• Comfort is key: Use your blanket and neck pillow. Ask for an ice pack, or ask if they could turn off a nearby overhead light. Small adjustments can make a big difference.
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• Use your toolkit: Your phone can be a distraction (avoid scrolling if it worsens symptoms). Quiet music, meditation, progressive muscle relaxation, or your migraine playlist might help.
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• Don't be afraid to rest: Even if it's a waiting room chair, close your eyes, put your head down if you can, and focus on slow breathing.
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• Advocate, then rest, then advocate again: It's exhausting but necessary. If the wait is long and your pain is escalating, restate your needs periodically: "My migraine now is a 9 instead of an 8, is there anything that can help?"
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Important Note: Emergency room triage is by the severity of the condition, not arrival order. Those with life-threatening emergencies will always be prioritized. It's frustrating, but understanding this can reduce feelings of being ignored.

Communicate Your Needs

Once you’re with the medical staff, be clear and direct about your symptoms. Describe the pain and any additional symptoms like nausea or light sensitivity. If you have a migraine action plan prepared with your doctor, now is the time to share it. Use more specific terms than vague ones. Do not ask for “something for the pain,” as that often is seen as ‘med seeking.’ Instead, say “my regular acute treatments have not helped and my pain is increasing.”
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Be specific about your pain:
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• Location: "Pain is throbbing behind my right eye."
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• Type: "Stabbing, crushing, burning..."
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• Intensity: "On a scale of 1-10, it's a 9 and getting worse." "My pain started in the orange but it's been in the red since 5pm."
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Describe ALL your symptoms: be specific about what happened when. If you have multiple auras, communicate which one was first and which followed. If you have MUMS, explain what MUMS is and how its symptoms chaotically unfold.
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• "I'm nauseous and cannot stop vomiting."
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• "Bright lights are blinding me."
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• "The noise is making my head pound even harder."
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• “The tingling has stopped on my arm but I still have tingling on my face.”
  
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Highlight what ISN'T working and what you react poorly to:
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• "I already took my [migraine medications] and they haven't helped."
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• "Lying down makes the nausea worse."
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Use "I need" statements:
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• "I need a dark, quiet room."
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• "I need something stronger for the pain."  or "I need a more effective pain management option"
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• "I need an anti-nausea medication."
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Don't be afraid to repeat yourself: ERs are hectic. If you haven't gotten what you need or if you’ve waited an incredibly long time for treatment, speak up again to a different nurse or the doctor.
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Additional Tips
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• Keep it short: When you're in agony, long explanations are hard. Focus on the most important symptoms and be as specific as possible.
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• Enlist support: Your companion (if you have one) can repeat your needs to staff.
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Remember, they want to help: ER staff are there to treat you; clear communication gets you the right care faster.

How to Self-Advocate
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It's important to speak up about what you need. If a treatment isn’t working, or if you feel your concerns aren’t being addressed, it’s okay to reiterate your symptoms or ask for alternatives. You know your body best.

Dealing With Aphasia

Migraine can sometimes cause aphasia and brain fog, which makes communication difficult. If this happens:
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• Use simple words and speak slowly.
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• Type what you want to say. If your aphasia is limited to spoken words, use your notes app or another phone communication app as your means of communication. Save a pre-typed message in your phone that explains that you experience aphasia and have difficulty speaking and explain how you understand language best (spoken or typed). This will save time when you first arrive.
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• Have a friend with you, if possible, who understands your condition and can help explain your situation to the medical staff. If your friend can’t be with you physically, ask if they can be on FaceTime or on the phone so they can help you communicate and self-advocate.
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• ‍Prepare ahead of time whenever you are at baseline, and put together a communication kit on your phone with statements you might need to make while you are there.
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You are not alone. Reach out to your Neura care coach for more tools and tips for a potential ER visit.

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Know your terms!
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Status migrainosus refers to a migraine attack that exceeds 72 hours and doesn't respond to your standard treatment course (including over-the-counter medications, prescription medications, and even some interventional procedures like nerve blocks or trigger point injections). This migraine complication can have more severe pain and symptoms. It also can be called intractable migraine.
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Why it's important:

• Status migrainosus attacks can be debilitating and disruptive.
• They often necessitate a visit to the ER for specialized medications and treatment.
• People experiencing intractable migraine are likely to benefit from seeing a neurologist or a headache specialist for management.
• If you go to the emergency room to treat status migrainosus and you do not get relief, schedule an emergency follow-up with your provider.

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