Stepwise management of acute headache in the emergency department 


1) Metoclopramide 10 mg IV or prochlorperazine 10 mg IV or droperidol 2.5 mg IV or haloperidol 5mg IV. Consider co-administering diphenhydramine 25mg IV to prevent akathisia, especially if using prochlorperazine; though this appears unnecessary if using metoclopramide. All medication should be administered over 5 to 

15 minutes. Add dexamethasone (either at the outset of care or prior to discharge) 10 mg 

IV to prevent headache recurrence. 


2) If insufficient relief: A second dose of the anti-dopaminergic plus ketorolac 15 mg IV. 


3) If insufficient relief: A third dose of either of the 

above medication plus DHE I mg IV over 15 

minutes. 


4) If insufficient relief: Consider greater occipital nerve block, emerging therapy listed in Table 2, or an opioid if the patient has no flags for opioid misuse. 


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