Migraine resident survival guide

Revision as of 15:44, 18 August 2020 by MoisesRomo (talk | contribs)
Jump to navigation Jump to search

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Moises Romo, M.D.

Overview

Migraine is a neurological disease best known for severe headaches.. Usually, migraine causes episodes of severe or moderate headache (which is often one-sided and pulsating) lasting between several hours to three days, accompanied by gastrointestinal upsets, such as nausea and vomiting, and a heightened sensitivity to bright lights (photophobia) and noise (phonophobia). Approximately one-third of people who experience migraine get a preceding aura. Migraines' secondary characteristics are inconsistent. Triggers precipitating a particular episode of migraine vary widely. The efficacy of the simplest treatment, applying warmth or coolness to the affected area of the head, varies between persons, sometimes worsening the migraine.

Causes

Common Causes

Management

 
 
 
Patient presents with a complaint of headache
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Does patient have new or different headaches in past 6 mo?
 
Yes
 
Evaluate red flags
• Systemic symptoms: fever, chills, meningismus
• Secondary risk factors: malignancy, immunosuppression
• Neurologic symptoms or abnormal signs
• Onset: sudden/abrupt
• Older age >50 years
• Pattern change: first headache or different from previous headache history
 
Yes to any
 
Appropriate pain management, consultations and admission
 
Appropriate evaluation for secondary causes
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
No
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
1. Are headaches recurrent that interfere with work, family or social function?
2. Do headaches last at least 4 h if untreated?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes to both questions
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Diagnose migraine
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Evaluate yellow flags
• Drug seeking with underlying chronic pain
• Recurrent ED visits without appropriate outpatient management/ PCP follow-up or
• OARRS report shows opiate use ± multisourcing
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Assess for treatment contraindications: pregnancy, allergies, comorbid conditions
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Avoid opioids
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Treat with
Ketorolac 30 mg IVP or 30-60 mg IM
+
Metoclopramide 10 mg IVP over 2 min or Ondansetron 8 mg IVP
+
Diphenhydramine 25-50 mg
+
IVP IV fl uids for hydration
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
More than 50% relief?
 
Yes
 
Discharge patient
1. Disposition


2. No opiate scripts
3. If responsive to ketorolac, discharge with toradol script 10 mg PO tid for up to 5 days


4. If response to sumatriptan, discharge with script
5. If response to DHE, discharge with Migranal nasal spray script or DHE sc script
6. If responsive to valproate, valproic taper 250 tid for 3 d, 250 bid for3 d, 250 qd for 3 d, then stop
7. Discharge with PCP follow-up

8. If no PCP, refer to PCP
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
No
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Treat with
Sumatriptan: 6 mg sc — may repeat in 1 h if no response. (Max dose 12 mg in 24-h period
OR
DHE-45: Start with 0.25 mg IVP over 1 min or sc. If needed repeat in 1 h 1 mg IVP over 1 min

or 1 mg sc. or choose an antiemetic: Prochlorperazine 10 mg IVP over 30 sec q2-4h prn
OR
Metoclopramide: 10 mg IVP over 2 min


OR
Ondansetron: 4-8 mg IVP over 30 sec
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
More than 50% relief?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
No
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Admit the patient and investigate further
 
 
 

Do's

Don'ts

References

Template:WS Template:WH