For acute migraine that is refractory to initial treatment in the emergency department, which therapy is used?

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When a migraine attack in the emergency department does not respond to initial therapy, a parenteral treatment that can rapidly abort the attack is preferred. IV dihydroergotamine fits this scenario because it is a potent vasoconstrictor that acts on several receptors involved in the migraine process, helping to reverse the cerebral vasodilation and trigeminovascular activation that underlie the attack. Giving it IV provides quick relief and is effective for refractory migraines or status migrainosus, often used alongside an antiemetic to control nausea and improve tolerability.

Oral acetaminophen, while safe, typically lacks the potency needed for refractory acute migraine. Subcutaneous lidocaine is not a standard, widely accepted abortive therapy for acute migraine in most emergency settings. Oral sumatriptan can be effective for many patients, but in the setting of refractory symptoms after initial treatment, IV dihydroergotamine is the traditional escalated option because of its broader mechanism and longer duration of action, making it more suitable for resisting attacks.