Migraine resident survival guide
|Migraine Resident Survival Guide Microchapters|
Synonyms and Keywords: approach to migraine, migraine workup, migraine management, migraine treatment
Migraines are a neurological disease best known as severe headaches. Usually, migraines cause 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 migraines 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.
- 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.
- 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
- 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
|Red flags |
•Headache beginning after 50 years old
•Increased severity and frequency of headaches
•Sudden onset of headache
•New onset of headache in cancer and HIV patients
•Headache with sign of systemic illness(fever,rash,neck stiffness)
•Focal neurological symptoms
•Headache subsequent to head trauma
|Refer and investigate|
|Possible indicators of secondary headache |
•Unexplained focal signs
•Unusual headache precipitatnts
•Unusual aura symptoms
•Onset after after age 50
•Agravatting by neck movement: abnormal neck examination findings (consider cervicogenic headache)
•Jaw symptoms (consider temporomandibular joint dysfunction)
•Monitor for medication overuse
•Prophylactic medication if:
-Headache >3 d/mo and acute medications are not effective
-Headache >8 d/mo (risk of overuse)
-Disability despite acute medication
|Headache with >2 of the following: |
•Interference with activities
•Migraine has been historically underdiagnosed
•Considere migraine diagnosis for recurring "sinus" headaches
|Medication overuse |
•Ergots, triptans, combination analgesics, or codeine or other opioids >10 d/mo
•Acetaminophen or NSAIDs >15 d/mo
•Considere prophylactic medication
•Provide an effective acute medication for severe attacks with limitations on frequency of use
•Gradual withdrawal of opioids if used, or combination analgesic with opioid or barbiturate
•Abrupt (or gradual) withdrawal of acetaminophen, NSAIDs or triptans
|Behavioral management |
•Keep headache diary: intensity, triggers, frequency, medications
•Adjust lifestyle factors: reduce caffeine, ensure regular exercise, avoid irregular or inadecuate sleep or meals
•Develope stress management strategies: relaxation training, CBI, pacing activity, biofeedback
|No||Tension type headache |
•Monitor for medication overuse
•Prophylactic medication disability despite medication
|Headache with no nausea but >2 of the following: |
•Not worsened by activity
Tension type headache
|Uncommon headache syndromes|
|All of the following: |
•Brief <3 h per attack)
•Unilateral (always same side)
•Ipsilateral eye redness, tearing or restleness during attacks
|All of the following: |
•Unilateral (always same side)
•Dramatically responsive to indomethacin
|Headache continuous side onset|
|Cluster headache or another trigeminal autonomic cephalalgia |
•Management primarly pharmacologic
•Early specialist referral recommended
|Hemicrania continua |
|New daily persistent headache |
|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|
|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|
|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|
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|
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
Sumatriptan: 6 mg sc — may repeat in 1 h if no response. (Max dose 12 mg in 24-h period
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
Ondansetron: 4-8 mg IVP over 30 sec
|More than 50% relief?|
|Admit the patient and investigate further|
- Be aware of patients who describe a sudden severe thunderclap headache, described as the worst headache of their lives. Perform a non-contrasted CT scan of the head to rule out subarachnoid hemorrhage; if negative, perform a lumbar puncture.
- Distinguish migraine from meningitis if in addition of photophobia and phonophobia, neck stiffness and fever coexist.
- Perform an MRI or CT scan of the head, if intracranial hypertension is suspected. Morning predominant headache accompanied by vomiting supports the diagnosis of intracranial tumors.
- Do not administer Drospirenone and Ethinyl estradiol or Norelgestromin and Ethinyl Estradiol in patients older than 35.
- Do not administer NSAIDs more than 15 days straight do to possible rebound headache.
- "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.
- "NINDS Migraine Information Page". National Institute of Neurological Disorders and Stroke, National Institutes of Health. Retrieved 2007-06-25.
- "Advances in Migraine Prophylaxis: Current State of the Art and Future Prospects" (PDF). National Headache Foundation (CME monograph). Retrieved 2007-06-25.
- "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.
- Ulrich V, Gervil M, Kyvik KO, Olesen J, Russell MB (1999). "The inheritance of migraine with aura estimated by means of structural equation modelling". Journal of Medical Genetics. 36 (3): 225–7. PMC 1734315. PMID 10204850. Retrieved 2012-08-30. Unknown parameter
- Gervil M, Ulrich V, Kaprio J, Olesen J, Russell MB (1999). "The relative role of genetic and environmental factors in migraine without aura". Neurology. 53 (5): 995–9. PMID 10496258. Retrieved 2012-08-30. Unknown parameter
- Becker WJ, Gladstone JP, Aubé M (November 2007). "Migraine prevalence, diagnosis, and disability". Can J Neurol Sci. 34 (4): S3–9. PMID 18064751.
- Latinovic R, Gulliford M, Ridsdale L (March 2006). "Headache and migraine in primary care: consultation, prescription, and referral rates in a large population". J Neurol Neurosurg Psychiatry. 77 (3): 385–7. doi:10.1136/jnnp.2005.073221. PMC 2077680. PMID 16484650.
- "An Algorithm of Migraine Treatment - touchNEUROLOGY".
- "Migraine and Meningitis | JAMA Neurology | JAMA Network".
- Montemayor ET, Long B, Pfaff JA, Moore GP (August 2018). "Patient with a Subarachnoid Headache". Clin Pract Cases Emerg Med. 2 (3): 193–196. doi:10.5811/cpcem.2018.5.38417. PMC 6075496. PMID 30083630.
- Sina F, Razmeh S, Habibzadeh N, Zavari A, Nabovvati M (August 2017). "Migraine headache in patients with idiopathic intracranial hypertension". Neurol Int. 9 (3): 7280. doi:10.4081/or.2017.7280. PMC 5641834. PMID 29071043.
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