Introduction: Despite optimal prophylactic therapy, some patients with migraine and chronic daily headache still suffer from breakthrough pain (BTP). When these patients present to emergency medicine (EM) physicians, complexities regarding management (including narcotic treatment) create multifaceted challenges. To date, no literature has been published on treatment contracts specifically designed to assist EM physician management of headache BTP. We present our anecdotal experience and report on the questionnaire-driven validation and improvement of our headache BTP ED treatment contracts. Methods: A questionnaire assessed EM physician satisfaction and feedback regarding breakthrough headache pain treatment contracts (in their initial form). Results: Attributed benefits included improved efficiency and safety in providing treatment with narcotics. EM physicians reported feeling reduced anxiety and liability with narcotic treatment. Reduced "negotiations" regarding appropriate therapy was felt to allow EM physicians to convey compassion and less suspicion. Of the 39 EM physicians polled, only 4 reported they were dissatisfied or equivocal regarding the headache BTP contracts (in their initial form). The most frequent suggestion concerned improved ways to alert the EM physician that the patient had a contract in place. Further improvements were suggested for pain physicians to incorporate to improve the positive impact of the treatment contracts. Conclusion: EM treatment of headache BTP can be significantly facilitated by treatment contracts conceived and modified specifically for the challenges of ER care.