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Migraine headaches are classified as a primary headache syndrome.Migraine Headache Migraine headaches are the fourth to fifth most common complaint in the emergency department, accounting for 3 million to 5 million ED visits annually.1,4 Although tension headaches are the most common primary headache disorder, migraines tend to be the most disabling and are more likely to present to the emergency department.1 Migraines have a 3:1 female to male ratio.5 Currently, there are several different treatment combinations available, which will be discussed further.Diagnostic Criteria The diagnostic criteria for migraines include those detailed in Table 1.5 Of note, the International Headache Society 2019 update further distinguishes migraines into aura and nonaura.6 According to the American College of Emergency Physicians 2019 Clinical Policy regarding evaluation and management of adult patients presenting to the emergency department with acute headache, subarachnoid hemorrhage should be ruled out using the Ottawa Subarachnoid Hemorrhage Rule (Table 2).7 Additional clinical findings such as pregnancy, postpartum women, fever, trauma, and severe back pain may warrant further evaluation before considering a migraine diagnosis.7Treatment Options Several different treatment combinations are available for migraines, including triptans, dihydroergotamine mesylate (DHE), 100% oxygen inhalation, ergotamine tartrate, opioids, nonsteroidal anti-inflammatory drugs (NSAIDs), antihistamines, acetaminophen, dexamethasone, ketorolac, and metoclopramide, to name a few.5,8 These treatments can be used as solitary treatments or in conjunction with other treatments listed, as appropriate. The adverse effects include increased blood pressure, chest pressure, dizziness, flushing, neck tightness, tingling, and limb heaviness.9,10 The contraindications to triptans are pregnancy, vascular disease, coronary artery disease, and uncontrolled hypertension.Dihydroergotamine Mesylate DHE can be given through several different routes, such as intramuscular (IM), intravenous (IV), subcutaneous, or intranasal. The contraindications include pregnancy, hypertension, angina, peripheral vascular disease or poor circulation, liver or kidney disease, serious infection, and arteriosclerosis.Opioids Opioids are certainly an option for treatment of migraines, although, considering the opioid epidemic, the American College of Emergency Physicians recommends preferentially using nonopioid medications for migraine treatment in the emergency department.7 Opioids should not be considered as first-line treatment. The contraindications include hypersensitivity to this class of medications and latex allergy; it has not been studied in pregnant or pediatric patients.Botox Injections Onabotulinum A (Botox) is thought to relax musculature secondary to blocking acetylcholine release at the neuromuscular junction, which reduces inflammation of the meninges and blocks pain signals coming from the brain.19 It was approved by the Food and Drug Administration in 2010 as a prophylactic therapy for chronic migraines in adults.18 Botox is given as an injection for migraines and is divided into 31 different sites approximately every 3 to 6 months.20 The adverse effects include toxin-effect spread, hypersensitivity reaction, anaphylaxis, injection-site reaction, and muscle weakness.

APRNs have existed for more than 50 years and are established members of emergency care teams throughout the United States (US) and in many countries worldwide.2-6 Nearly a decade ago, the Institute of Medicine identified APRNs as necessary for the future of health care delivery in the US.7,8 Since then emergency departments (EDs) in the US and abroad have become increasingly overcrowded, in part due to their status as a health care safety net for those who cannot access a primary care provider.9,10 It is estimated that EDs provide more than 47% of all hospital-associated health care in the US.9 As a result, there is currently a substantial mismatch between the need for emergency services and the available resources to provide that care.10 APRNs have been identified as particularly important for bridging this gap in both urban and rural settings.11-14 The regulatory landscape for APRNs in the US continues to evolve, and APRNs who work in the emergency care setting face a few unique licensing and certification challenges. The Consensus Model’s licensing paradigm could create barriers to APRN practice in the emergency care setting because it would require APRNs who treat the full population of the emergency care setting to complete three courses of graduate study and to obtain and maintain three certifications (eg, Family Nurse Practitioner, Adult-Gerontological Acute Care Nurse Practitioner, and Pediatric Acute Care Nurse Practitioner).1,17 CNSs, for whom there are fewer courses of study than for NPs, would be required to have and maintain 2 licenses (Adult-Gerontology CNS and Pediatric CNS), but they would be restricted to either primary or acute care.18ENA Position The following are the positions of the Emergency Nurses Association (ENA): APRNs are established members of the emergency care team and are critical to the future of quality health care across the US and worldwide. Background The emergency care setting is unique when compared to most other practice settings in that its patient population consists of all ages and all combinations of medical history and chief complaint, rather than a narrow subset of them, as is the case with most other specialties (eg, pediatric oncology, adult cardiology, etc).19 Although some APRNs only treat a subset of the patients in the emergency care setting, for example, only pediatric patients or only adults with urgent or chronic needs, other APRNs are called upon to treat all patients and conditions, from nonemergent, episodic chronic care to acute, complex, life-threatening traumatic and medical conditions.2,20-23 APRNs are licensed and regulated by state law, and reciprocity across state lines is determined by each state. The Consensus Model’s proposal that US states license APRNs as “primary care” or “acute care” APRNs, along with its stipulation that an APRN only be allowed to expand his or her scope of practice by completing another graduate program of study, stands in contrast to how APRNs are currently licensed and regulated today.24-29 In nearly all states, APRNs are licensed at the role level, and the scope of practice is determined not only by formal education and national certification but by clinical experience as well.30 Degree-granting programs are designed to prepare APRNs for entry-level competency, and postgraduate training after one’s formal course of education confers clinical expertise.6,29,31-34 It is, therefore, no surprise that APRNs who are currently providing safe and effective primary and acute care across the country are certified as family nurse practitioners (FNPs), acute care nurse practitioners (ACNPs), Adult NPs, Pediatric NPs, Adult-Gerontological NPs, Adult-Gerontological CNSs, and Pediatric CNSs, among others.15,21,35,36 The Consensus Model has been a powerful force for raising the quality of APRN education and training in the US and has successfully championed full practice authority for APRNs in all states.15 Regardless of the outcome of these and future discussions over whether and how to implement the Consensus Model’s definitions of primary care, acute care, and scope of practice, APRNs will continue their long tradition of providing safe, effective care in the emergency care setting, and ENA will remain committed to interprofessional collaboration and advocacy on their behalf.Resources Advanced Practice Registered Nursing Consensus Work Group, The National Council of State Boards of Nursing APRN Advisory Committee.