Migraine resident survival guide
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
- Life-threatening causes include conditions that may result in death or permanent disability within 24 hours if left untreated.
- There are no life-threatening causes of migraine, although, migraine should be distinguished from intracranial berry aneurysms ruptures and subarachnoid hemorrhages, which represent real emergencies.
Common Causes
- Allergic reactions
- Bright lights, loud noises, and certain odors or perfumes
- Physical or emotional stress
- Changes in sleep patterns
- Smoking or exposure to smoke
- Skipping meals
- Alcohol
- Caffeine
- Menstrual cycle fluctuations, birth control pills
- Exposure to pesticides (sprayed fruits/vegetables)
- Tension headaches
- Foods containing tyramine (red wine, aged cheese, smoked fish, chicken livers, figs, and some beans), monosodium glutamate (MSG), or nitrates (like bacon, hot dogs, and salami)
- Other foods such as chocolate, nuts, peanut butter, avocado, banana, citrus, onions, dairy products, and fermented or pickled foods.
- Drugs like apremilast, conjugated estrogens, Cidofovir
Management
- Shown below is an algorithm summarizing the treatment of migraine according the American Academy of Neurology guidelines:
| 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
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 Ondansetron: 4-8 mg IVP over 30 sec | |||||||||||||||||||||||||||||||||||||||||||||||||||||
| More than 50% relief? | |||||||||||||||||||||||||||||||||||||||||||||||||||||
| No | |||||||||||||||||||||||||||||||||||||||||||||||||||||
| Admit the patient and investigate further | |||||||||||||||||||||||||||||||||||||||||||||||||||||