Episode Details

Date: January 5, 2026 Reference: Robblee et al. 2025 guideline update to acute treatment of migraine for adults in the emergency department: The American Headache Society evidence assessment of parenteral pharmacotherapies. Headache 2025 Dec Happy New Year, SGEMers! What better way to start 2026 than with an SGEM Xtra about migraine headaches? We were originally scheduled to record this episode in December, but circumstances changed. This is another SGEM Xtra and not the typical structured critical appraisal with a checklist. It will be a conversation about what we should be doing and should stop doing when treating migraine patients in the ED based on the new American Headache Society (AHS) guidelines. However, you will find a standard SGEM nerdy critical appraisal at the end of this blog post. Migraine is one of the most common causes of headache visits to the ED, representing ~¼ of the 3.5 million annual headache-related visits in the US. Despite prior guidelines, ED practice is still all over the map, and patients sometimes leave without much relief. The AHS has just released the 2025 guideline update on parenteral pharmacotherapies and nerve blocks for adult ED migraine. To help us understand these new guidelines, we are joined by two neurologists who literally wrote the guidelines. Dr. Jennifer Robblee Dr. Jennifer Robblee (lead guideline author) is a Board‑certified neurologist and headache specialist at Barrow Neurological Institute in Phoenix. Her practice focuses on refractory migraine and status migrainosus. She trained at the University of Toronto (MD, neurology residency, MSc) and completed a headache fellowship at the Mayo Clinic Scottsdale.  Jennifer is the third eurologist to be on the SGEM. We’ve had Dr. Jeff Saver and Dr. Ravi Garg discuss thrombolytics and stroke. This will be an example that not all of neurology and emergency medicine intersect over stroke care.  Dr. Serena Orr Dr. Serena Orr (senior guideline author) is a pediatric neurologist, headache subspecialist, and director of the pediatric headache program at Alberta Children’s Hospital in Calgary. Serena has a strong interest in acute treatment of migraine, tech‑based treatment solutions, and psychosocial factors affecting migraine in kids and teens. The AHS guideline committee uses a 5-year update cycle for guidelines. Since 2016, 26 new RCTs and 20 injectable treatments, including nerve blocks (GONB, SONB, SPG) and eptinezumab.  Unfortunately, ED migraine outcomes are still not great. Only ~37% of ED patients achieve headache freedom at discharge. These new guidelines were trying to answer two questions.  Which injectable meds are effective in adults with migraine in the ED? Are nerve blocks effective in adults with migraine in the ED?  Top 5 things ED should know about the 2025 AHS Migraine Guidelines Listen to the SGEM podcast to hear Jennier and Serena discuss the top five things emergency physicians should know about the 2025 migraine guidelines. 1. Prochlorperazine IV & Greater Occipital Nerve Blocks (GONB) Are Now Level A “Must Offer” IV prochlorperazine and greater occipital nerve blocks (GONB) are Level A - must offer or adults presenting to the ED with a migraine attack requiring parenteral therapy (if no contraindications).  Questions: This is a big upgrade from 2016. Why did prochlorperazine and GONB earn Level A status in 2025? Practically, what does that look like in an ED order set? Are you imagining that everyone gets prochlorperazine? For the EM docs who have not been performing occipital nerve blocks, how steep is the learning curve? 2. Hydromorphone Is Level A “Must NOT Offer” Hydromorphone IV: Level A - Must NOT offer for migraine in the ED.  Questions: Let’s talk about opioids. Hydromorphone is now ‘must NOT offer’, what tipped the scale to Level A harm/no benefit? “Must NOT offer” seems like a strong statement (thou shalt not), is there not a potential clinical situation where