Migraine resident survival guide: Difference between revisions

Jump to navigation Jump to search
No edit summary
No edit summary
Line 4: Line 4:
Migraine is a [[neurology|neurological]] disease best known for severe headaches that are its most salient symptom.<ref>{{cite web | title =  NINDS Migraine Information Page | work= National Institute of Neurological Disorders and Stroke, National Institutes of Health | url = http://www.ninds.nih.gov/disorders/migraine/migraine.htm | accessdate=2007-06-25}}</ref><ref>{{cite web | title = Advances in Migraine Prophylaxis: Current State of the Art and Future Prospects| work= National Headache Foundation (CME monograph) | url = http://www.headaches.org/professional/educationresources/PDF/botoxcme.pdf  | accessdate=2007-06-25}}</ref><ref>{{cite web | title = Migraine: diagnosis, management, and new treatment options, Gallagher RM, Cutrer FM, University of Medicine and Dentistry of New Jersey, School of Medicine, Stratford, USA| work = The American Journal of Managed Care, PMID: 11859906 | url = http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=11859906&ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus | accessdate=2007-06-25}}</ref>. 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 (symptom)|aura]].<ref>{{cite web |title = Guidelines for all healthcare professionals in the diagnosis and management of migraine, tension-type, cluster and medication-overuse headache, Jan 2007,British Association for the Study of Headache| | url = http://216.25.100.131/upload/NS_BASH/BASH_guidelines_2007.pdf |accessdate=2007-06-25}}</ref> Migraines' secondary characteristics are inconsistent. ''[[#Triggers|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.<ref>''The Essential Book of Herbal Medicine'' (also known as ''Out of the Earth'') by Simon Y. Mills, Viking Arkana, 1994(1991). Mills is a former president of the UK licensed medical herbalists association. Mills' point is the traditional classification of migraines into "hot" and "cold" types, meaning that one's migraine type is determined by whether one's pain is reduced by hot/warm versus cold water.</ref>
Migraine is a [[neurology|neurological]] disease best known for severe headaches that are its most salient symptom.<ref>{{cite web | title =  NINDS Migraine Information Page | work= National Institute of Neurological Disorders and Stroke, National Institutes of Health | url = http://www.ninds.nih.gov/disorders/migraine/migraine.htm | accessdate=2007-06-25}}</ref><ref>{{cite web | title = Advances in Migraine Prophylaxis: Current State of the Art and Future Prospects| work= National Headache Foundation (CME monograph) | url = http://www.headaches.org/professional/educationresources/PDF/botoxcme.pdf  | accessdate=2007-06-25}}</ref><ref>{{cite web | title = Migraine: diagnosis, management, and new treatment options, Gallagher RM, Cutrer FM, University of Medicine and Dentistry of New Jersey, School of Medicine, Stratford, USA| work = The American Journal of Managed Care, PMID: 11859906 | url = http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=11859906&ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus | accessdate=2007-06-25}}</ref>. 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 (symptom)|aura]].<ref>{{cite web |title = Guidelines for all healthcare professionals in the diagnosis and management of migraine, tension-type, cluster and medication-overuse headache, Jan 2007,British Association for the Study of Headache| | url = http://216.25.100.131/upload/NS_BASH/BASH_guidelines_2007.pdf |accessdate=2007-06-25}}</ref> Migraines' secondary characteristics are inconsistent. ''[[#Triggers|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.<ref>''The Essential Book of Herbal Medicine'' (also known as ''Out of the Earth'') by Simon Y. Mills, Viking Arkana, 1994(1991). Mills is a former president of the UK licensed medical herbalists association. Mills' point is the traditional classification of migraines into "hot" and "cold" types, meaning that one's migraine type is determined by whether one's pain is reduced by hot/warm versus cold water.</ref>
==Causes==
==Causes==
Disease name] may be caused by [cause1], [cause2], or [cause3].
Life-threatening causes include conditions that may result in death or permanent disability within 24 hours if left untreated.
* [[Life threatening cause 1]]
* [[Life threatening cause 2]]
* [[Life threatening cause 3]]


OR
===Common Causes===
 
* [[Common cause 1]]
Common causes of [disease] include [cause1], [cause2], and [cause3].
* [[Common cause 2]]
 
* [[Common cause 3]]
OR
* [[Common cause 4]]
 
* [[Common cause 5]]
The most common cause of [disease name] is [cause 1]. Less common causes of [disease name] include [cause 2], [cause 3], and [cause 4].
 
OR
 
The cause of [disease name] has not been identified. To review risk factors for the development of [disease name], click [[Pericarditis causes#Overview|here]].
==Management==
==Management==



Revision as of 13:48, 18 August 2020

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 that are its most salient symptom.[1][2][3]. 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.[4] 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.[5]

Causes

Life-threatening causes include conditions that may result in death or permanent disability within 24 hours if left untreated.

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
 
 
 

Diagnostic clues

Risk Factors

  • Common risk factors in the development of [disease name] are [risk factor 1], [risk factor 2], [risk factor 3], and [risk factor 4].

Natural History, Complications and Prognosis

  • The majority of patients with [disease name] remain asymptomatic for [duration/years].
  • Early clinical features include [manifestation 1], [manifestation 2], and [manifestation 3].
  • If left untreated, [#%] of patients with [disease name] may progress to develop [manifestation 1], [manifestation 2], and [manifestation 3].
  • Common complications of [disease name] include [complication 1], [complication 2], and [complication 3].
  • Prognosis is generally [excellent/good/poor], and the [1/5/10­year mortality/survival rate] of patients with [disease name] is approximately [#%].

Diagnosis

Do's

Don'ts

References

  1. "NINDS Migraine Information Page". National Institute of Neurological Disorders and Stroke, National Institutes of Health. Retrieved 2007-06-25.
  2. "Advances in Migraine Prophylaxis: Current State of the Art and Future Prospects" (PDF). National Headache Foundation (CME monograph). Retrieved 2007-06-25.
  3. "Migraine: diagnosis, management, and new treatment options, Gallagher RM, Cutrer FM, University of Medicine and Dentistry of New Jersey, School of Medicine, Stratford, USA". The American Journal of Managed Care, PMID: 11859906. Retrieved 2007-06-25.
  4. "Guidelines for all healthcare professionals in the diagnosis and management of migraine, tension-type, cluster and medication-overuse headache, Jan 2007,British Association for the Study of Headache" (PDF). Retrieved 2007-06-25.
  5. The Essential Book of Herbal Medicine (also known as Out of the Earth) by Simon Y. Mills, Viking Arkana, 1994(1991). Mills is a former president of the UK licensed medical herbalists association. Mills' point is the traditional classification of migraines into "hot" and "cold" types, meaning that one's migraine type is determined by whether one's pain is reduced by hot/warm versus cold water.

Template:WS Template:WH