How to Know if Your Migraine Warrants a Trip to the ER

Migraine can get worse without any underlying causes. The natural history of migraine is that it ebbs and flows. Many times, you can be doing well for a long time and then — without a clear inciting incident — the headaches start to increase in frequency.

We like to treat it preventively before it gets to that point, if possible. So when you start to notice your migraine getting worse, let your doctor know right away. However, migraine can occasionally get so bad that it requires visiting the emergency room. If other options have been exhausted and you are concerned about sudden changes in how your migraine presents, it’s time to start treating the situation as an emergency.

Warning Signs

A visit to the emergency room or admission to a hospital can definitely be warranted when a migraine is lasting a very long time; we usually say the cutoff is three days. Other neurological symptoms that you don’t normally experience with your headaches — such as dizziness, weakness on one side, speech disturbance or fever —could indicate other problems at play.

The term we like to use is “SNOOP,” which is an acronym for the kinds of red flags that need to be addressed by a specialist:

• Systemic symptoms such as a fever or another illness together with the headache.
• Neurological signs or symptoms like numbness, tingling, weakness, speech disturbance, vertigo or dizziness, and other similar symptoms you don’t normally experience.
• Onset. The headache is rapidly becoming severe.
• Older. If you are 50 years old or older and you’re starting to experience headaches for the first time, that in and of itself is a red flag.
• Positionality. The headache is much better when you’re lying down and much worse when you’re standing up, or vice versa.

Before Going to the ER

Patients should always try their abortive strategies and medications first or reach out to their specialist. There’s a separate category of medicines that we use if we think things are getting slightly worse, but before they’ve gotten to the point where a patient needs to go to the ER. We sometimes use short-term preventive — or “bridge” — treatments, which are medications that we don’t like using for long periods of time, but we’ll use for shorter periods to break up a really bad cycle. Those can consist of anti-inflammatory medicines, steroids and sometimes anti-nausea medications, among other kinds of treatments.

Play It Safe

One rule most of us have about migraine is that fewer migraines beget fewer migraines, and more migraines beget more migraines. Any time you start to notice migraine getting worse, it’s time to seek help. If there’s anything that feels different about the headache, see a doctor and get it checked out — even if it’s not your doctor or headache specialist.

Migraine itself can never really be fatal. However, other things that can also cause headache theoretically can be. That’s why we have to make sure it isn’t something like a hemorrhage or an aneurysm when we talk about these red flags. If there’s something different about the headache, you should be seen either by your primary care doctor, or, potentially, the emergency room, because something else could be at play.

Dr. Berk is a neurologist and an Assistant Professor at the Department of Neurology and Division of Headache Medicine at NYU Langone Health. He works closely with the American Migraine Foundation to educate others about migraine.