SGEM Xtra: Hit Me with Your Best Block – 2025 AHS ED Migraine Guidelines | The Skeptics Guide to Emergency Medicine

The podcast addresses migraine treatment in emergency departments, focusing on the American Headache Society's updated 2025 guidelines. Neurologists Dr. Jennifer Robb-Lee and Dr. Selena Orr, guideline authors, discuss key changes and recommendations. Prochlorperazine and greater occipital nerve blocks are now level A "must-offer" treatments due to new studies demonstrating their efficacy, while hydromorphone is downgraded to "must not offer" because of safety concerns and the availability of better alternatives. The discussion also explores practical implementation of nerve blocks, the role of dexamethasone, and the need for more patient-centered research in migraine treatment.

Outlines

Part 1: Introduction, Context

Part 2: Guideline Updates, Clinical Questions

Part 3: Treatment Protocols, Recommendations

Part 4: Research Gaps, Pediatric Care

Part 5: Methodology, Limitations

Part 6: Future Outlook, Conclusions

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

The Skeptics Guide to Emergency Medicine

Part 1: Introduction, Context

Introduction to Migraine Headaches and the 2025 AHS ED Guidelines

Jennifer Robb-Lee's Journey to Headache Specialization and Migraine Diagnosis Nuances

Serena Orr's Serendipitous Path to Migraine Guidelines and Addressing Practice Variation

Part 2: Guideline Updates, Clinical Questions

Motivations for Updating Migraine Guidelines and Key Clinical Questions Addressed

Top Recommendations: Prochlorperazine, GONB, and the Upgrade to Level A Status

Part 3: Treatment Protocols, Recommendations

Hydromorphone: A Level A "Must Not Offer" Recommendation and Opioid Concerns

Level B Recommendations: IV NSAIDs, Metoclopramide, Triptans, and Supraorbital Nerve Blocks

Dexamethasone, Nerve Block Integration, and Implementation Challenges in the ED

Part 4: Research Gaps, Pediatric Care

Evidence Gaps, Patient-Oriented Outcomes, and Future Research Directions

Pediatric Migraine Research: Non-Parenteral Treatments and Patient-Centered Approaches

Part 5: Methodology, Limitations

Limitations: Risk of Bias Tools, Study Quality Nuance, and External Validity

Addressing External Validity and Active Comparators of Unclear Significance

Narrative Synthesis and the Avoidance of Inappropriate Meta-Analyses

Part 6: Future Outlook, Conclusions

Guidelines vs. RCTs, Publication Bias, and the Need for ED-Specific Trial Guidelines

Future Goals: Homogeneous Studies, Non-Invasive Options, and Collaborative Efforts

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

The Skeptics Guide to Emergency Medicine

Part 1: Introduction, Context

00:10Introduction to Migraine Headaches and the 2025 AHS ED Guidelines

Introduction to Migraine Headaches and the 2025 AHS ED Guidelines

02:32Jennifer Robb-Lee's Journey to Headache Specialization and Migraine Diagnosis Nuances

Jennifer Robb-Lee's Journey to Headache Specialization and Migraine Diagnosis Nuances

07:03Serena Orr's Serendipitous Path to Migraine Guidelines and Addressing Practice Variation

Serena Orr's Serendipitous Path to Migraine Guidelines and Addressing Practice Variation

Part 2: Guideline Updates, Clinical Questions

13:47Motivations for Updating Migraine Guidelines and Key Clinical Questions Addressed

Motivations for Updating Migraine Guidelines and Key Clinical Questions Addressed

16:50Top Recommendations: Prochlorperazine, GONB, and the Upgrade to Level A Status

Top Recommendations: Prochlorperazine, GONB, and the Upgrade to Level A Status

Part 3: Treatment Protocols, Recommendations

25:09Hydromorphone: A Level A "Must Not Offer" Recommendation and Opioid Concerns

Hydromorphone: A Level A "Must Not Offer" Recommendation and Opioid Concerns

28:42Level B Recommendations: IV NSAIDs, Metoclopramide, Triptans, and Supraorbital Nerve Blocks

Level B Recommendations: IV NSAIDs, Metoclopramide, Triptans, and Supraorbital Nerve Blocks

35:01Dexamethasone, Nerve Block Integration, and Implementation Challenges in the ED

Dexamethasone, Nerve Block Integration, and Implementation Challenges in the ED

Part 4: Research Gaps, Pediatric Care

43:10Evidence Gaps, Patient-Oriented Outcomes, and Future Research Directions

Evidence Gaps, Patient-Oriented Outcomes, and Future Research Directions

46:00Pediatric Migraine Research: Non-Parenteral Treatments and Patient-Centered Approaches

Pediatric Migraine Research: Non-Parenteral Treatments and Patient-Centered Approaches

Part 5: Methodology, Limitations

49:07Limitations: Risk of Bias Tools, Study Quality Nuance, and External Validity

Limitations: Risk of Bias Tools, Study Quality Nuance, and External Validity

53:14Addressing External Validity and Active Comparators of Unclear Significance

Addressing External Validity and Active Comparators of Unclear Significance

59:09Narrative Synthesis and the Avoidance of Inappropriate Meta-Analyses

Narrative Synthesis and the Avoidance of Inappropriate Meta-Analyses

Part 6: Future Outlook, Conclusions

1:01:12Guidelines vs. RCTs, Publication Bias, and the Need for ED-Specific Trial Guidelines

Guidelines vs. RCTs, Publication Bias, and the Need for ED-Specific Trial Guidelines

1:07:32Future Goals: Homogeneous Studies, Non-Invasive Options, and Collaborative Efforts

Future Goals: Homogeneous Studies, Non-Invasive Options, and Collaborative Efforts