SGEM Xtra: Hit Me with Your Best Block – 2025 AHS ED Migraine Guidelines

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 an opioid still should be offered? How do we balance real‑world pressures, patient expectations, throughput, Press Ganey scores with an anti‑opioid, evidence‑based stance? It’s going to impact ED docs and not neurologists. 3. The Level B Recommendations:  Level B - “Should offer” for headache requiring parenteral therapy (Dexketoprofen IV, ketorolac IV, metoclopramide IV, subcutaneous sumatriptan, and supraorbital nerve blocks [SONB]).  Dexamethasone IV remains Level B “should offer” for recurrence prevention from the 2016 guidance.  Questions: If Level A is your starting lineup, who’s on the bench as your Level B ‘should offer’ options, and when do you pull them in? Is there a preferred sequence – dopamine antagonist first, then NSAID, then triptan, or is it more patient‑specific? How should ED clinicians think about dexamethasone? Is it still a routine add‑on, or more selective? 4. Nerve Blocks Are Mainstream GONB: Level A - Must offer. SONB: Level B - May/should offer when GONB is insufficient or not possible.  Questions: For a busy ED, how realistic is it to integrate occipital and supraorbital nerve blocks into standard migraine care? What’s the pragmatic advice on training?   Can EM doctors become competent with blocks via bedside teaching and FOAMed resources> 5. Big Evidence Gaps No meta‑analyses were possible because of significant heterogeneity in methods and outcomes. Additional ED-specific outcomes, such as pain relief at 1 hour. Asking about patient-oriented outcomes (POO) such as “Would you want this treatment again on your next ED visit?” Need ED‑specific data on eptinezumab (currently Level U for general ED use despite strong outpatient data).  Questions: If you had unlimited funding for one ED migraine randomized control trial, what would you test, and what outcome would you choose? You recommended a 1‑hour endpoint for ED trials. How does that change how we design and interpret future studies? I love the idea of the patient-centred outcome: ‘Would you want this again?’ How do we make sure future trials include that kind of measure? Five Limitations of the AHS Migraine Guideline The goal here is not to dunk on the guideline; there are limitations to any study.  This is just a nerdy conversation about how the next cycle could be improved. Listen to the SGEM Xtra podcast to hear Jennifer and Serena respond.  Limitation 1: Risk of Bias Tool & Study Quality Nuances Question: “You explicitly say that some ‘class I’ RCTs had small sample sizes or weird time points that made you less confident. From an EBM standpoint, how did you reconcile the AAN RoB categories with what we’d call imprecision and indirectness in GRADE?” Limitation 2: External Validity - Not All RCTs Were ED RCTs Question: “Many of the trials you had to work with weren’t actually done in ED settings – eptinezumab and SPG blocks being two examples. How worried should we be about extrapolating outpatient data into the ED, where patients are often later in the attack, more distressed, and maybe have different comorbidities?” Limitation 3: Active Comparators of Unclear Significance Question: “You call out trials that compare against ‘iffy’ active controls (valproate, dexamethasone, etc). In EBM terms, this muddies the signal. If you beat a weak comparator, is your drug actually good? How did you handle that when grading evidence and crafting recommendations?” Limitation 4: No Meta‑Analyses; Reliance on Narrative Synthesis Question: “From a methodological point of view, the fact that you couldn’t meta‑analyze anything limits precision and makes it hard to quantify effect sizes. How should EM clinicians interpret Level A or B recommendations that rest on narrative synthesis instead of pooled estimates?” Limitation 5: Broader Biases - Publication, Selection, and the ED Reality Question: “Zooming way out, every guideline sits on top of the published RCT iceberg. How much do you worry about publication bias, selection bias, and the fact that ED patients we see at 3 am rarely look like the trial population?” Remember to be skeptical of anything you learn, even if you heard it on the Skeptics’ Guide to Emergency Medicine.  Critical Appraisal 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 Background: Migraine is one of the most common reasons people roll into the ED with a headache, and it’s not just “a bad headache.” It’s a chronic neurologic disorder that affects over a billion people globally and is consistently among the top causes of years lived with disability, especially in young and middle-aged adults [1.2].  In the ED specifically, migraine accounts for about one‑quarter of the ~3.5 million headache-related visits per year in the US. That’s a lot of stretchers tied up with photophobic patients in dark rooms. Clinically, migraine is defined by the International Classification of Headache Disorders (ICHD‑3). Typical attacks last 4 to 72 hours and are moderate to severe, often unilateral, pulsating, and worsened by routine physical activity. They’re commonly accompanied by nausea and/or vomiting and photophobia/phonophobia [3]. Migraine without aura is the most common type; migraine with aura adds transient focal neurologic symptoms (usually visual) that precede or accompany the headache. Diagnosis in the ED is clinical: apply ICHD‑3 criteria, look for a typical migraine phenotype, and screen for red flags (fever, meningeal signs, focal deficits, thunderclap onset, immunocompromise, anticoagulation, etc.) to rule out secondary causes. Outside the ED,