Of the 1.2 million people who present to the emergency department (ED) each year for migraine treatment, more than half are treated with opioids despite known risks. 
There is also significant variation in the types of medications used, which prompted the American Headache Society to convene an expert panel to review the evidence and determine which medications should be considered first-line treatment.
A total of 68 studies involving 28 different medications were ultimately included in the review. Intravenous metoclopramide and prochlorperazine, and subcutaneous sumatriptan should be offered to eligible adults who present to an ED with acute migraine (Level B). Dexamethasone should be offered to these patients to prevent recurrence of headache (Level B). Because of lack of evidence demonstrating efficacy and concern about sub-acute or long-term sequelae, injectable morphine and hydromorphone are best avoided as first-line therapy (Level C).
In a similar fashion, the Canadian Headache Society after a systematic review recommend the use of metoclopramide and sumatriptan, based on a moderate level of evidence, and ketorolac, based on a low level of evidence as first line agents .
However, if the patient has relative contraindications to each of these, other parenteral medications used for migraine are listed below with no order of efficacy.
Hijinio Carreon DO
1. Leniger T, Pageler L, Stude P, Diener HC, Limmroth V. Comparison of intravenous valproate with intravenous lysine-acetylsalicylic acid in acute migraine attacks. Headache 2005;45:42-6.
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3. Shahrami A, Assarzadegan F, Hatamabadi HR, Asgarzadeh M, Sarehbandi B, Asgarzadeh S. Comparison of therapeutic effects of magnesium sulfate vs. dexamethasone/metoclopramide on alleviating acute migraine headache. J Emerg Med 2015;48:69-76.
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8. Winner P, Ricalde O, Le Force B, Saper J, Margul B. A double-blind study of subcutaneous dihydroergotamine vs subcutaneous sumatriptan in the treatment of acute migraine. Arch Neurol 1996;53:180-4.
9. Turkcuer I, Serinken M, Eken C, et al. Intravenous paracetamol versus dexketoprofen in acute migraine attack in the emergency department: a randomised clinical trial. Emergency medicine journal : EMJ 2014;31:182-5.
10. Leinisch E, Evers S, Kaempfe N, et al. Evaluation of the efficacy of intravenous acetaminophen in the treatment of acute migraine attacks: a double-blind, placebo-controlled parallel group multicenter study. Pain 2005;117:396-400.
11. Gaffigan ME, Bruner DI, Wason C, Pritchard A, Frumkin K.J, A Randomized Controlled Trial of Intravenous Haloperidol vs. Intravenous Metoclopramide for Acute Migraine Therapy in the Emergency Department. Emerg Med. 2015 Sep;49(3):326-34. doi: 10.1016/j.jemermed.2015.03.023. Epub 2015 Jun 2.
12. Orr SL, Aube M, Becker WJ, et al. Canadian Headache Society systematic review and recommendations on the treatment of migraine pain in emergency settings. Cephalalgia 2015;35:271-84.
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14. Orr SL, Friedman BW, Christie S, Minen MT, Bamford C, Kelley NE, Tepper D. Management of Adults With Acute Migraine in the Emergency Department: The American Headache Society Evidence Assessment of Parenteral Pharmacotherapies. 2016. Headache. 2016; 56:911–940.