Migraine resident survival guide: Difference between revisions

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==Overview==
==Overview==
[[Migraine]] is a [[neurology|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 (symptom)|aura]]. 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]].
[[Migraine]] is a [[neurology|neurological]] disease best known for severe [[headaches]].<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.<ref name="pmid10204850">{{cite journal |author=Ulrich V, Gervil M, Kyvik KO, Olesen J, Russell MB |title=The inheritance of migraine with aura estimated by means of structural equation modelling |journal=[[Journal of Medical Genetics]] |volume=36 |issue=3 |pages=225–7 |year=1999 |month=March |pmid=10204850 |pmc=1734315 |doi= |url=http://jmg.bmj.com/cgi/pmidlookup?view=long&pmid=10204850 |accessdate=2012-08-30}}</ref><ref name="pmid10496258">{{cite journal |author=Gervil M, Ulrich V, Kaprio J, Olesen J, Russell MB |title=The relative role of genetic and environmental factors in migraine without aura |journal=[[Neurology]] |volume=53 |issue=5 |pages=995–9 |year=1999 |month=September |pmid=10496258 |doi= |url=http://www.neurology.org/cgi/pmidlookup?view=long&pmid=10496258 |accessdate=2012-08-30}}</ref> 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==
==Causes==


Line 27: Line 27:
==Management==
==Management==


* Shown below is an [[algorithm]] summarizing the [[treatment]] of [[migraine]] according the American Academy of Neurology guidelines:
* Shown below is an [[algorithm]] summarizing the [[treatment]] of [[migraine]] according the American Academy of Neurology guidelines:<ref name="urlAn Algorithm of Migraine Treatment - touchNEUROLOGY">{{cite web |url=https://touchneurology.com/headache/journal-articles/an-algorithm-of-migraine-treatment/ |title=An Algorithm of Migraine Treatment - touchNEUROLOGY |format= |work= |accessdate=}}</ref><ref name="urlwww.painmedicinenews.com">{{cite web |url=https://www.painmedicinenews.com/Article/PrintArticle?articleID=33453 |title=www.painmedicinenews.com |format= |work= |accessdate=}}</ref><ref name="urlMigraine and Meningitis | JAMA Neurology | JAMA Network">{{cite web |url=https://jamanetwork.com/journals/jamaneurology/article-abstract/579362 |title=Migraine and Meningitis &#124; JAMA Neurology &#124; JAMA Network |format= |work= |accessdate=}}</ref>
{{Family tree/start}}
{{Family tree/start}}
{{Family tree | | | | A01 | | | |A01= Patient presents with a complaint of headache
{{Family tree | | | | A01 | | | |A01= Patient presents with a complaint of [[headache]]
}}
}}
{{Family tree | | | | |!| | | | | }}
{{Family tree | | | | |!| | | | | }}
{{Family tree | | | | A01 |-| A02 |-| A03 |-| A04 |-| A05 |-| A06 | |A01= Does patient have new or different headaches in past 6 mo?
{{Family tree | | | | A01 |-| A02 |-| A03 |-| A04 |-| A05 |-| A06 | |A01= Does patient have new or different [[headaches]] in past 6 mo?
| A02= Yes| A03= Evaluate red flags<br> • Systemic symptoms: fever, chills, meningismus<br>• Secondary risk factors: malignancy, immunosuppression <br>• Neurologic symptoms or abnormal signs <br>• Onset: sudden/abrupt <br>• Older age >50 years <br>• Pattern change: first headache or different from previous
| A02= Yes| A03= Evaluate [[red flags]]<br> • Systemic [[symptoms]]: [[fever]], [[chills]], [[meningismus]]<br>• Secondary [[risk factors]]: [[malignancy]], [[immunosuppression]] <br>• [[Neurologic symptoms]] or abnormal signs <br>• Onset: sudden/abrupt <br>• Older age >50 years <br>• Pattern change: first [[headache]] or different from previous
  headache history | A04= Yes to any | A05= Appropriate pain management, consultations
  headache history | A04= Yes to any | A05= Appropriate pain management, consultations
  and admission | A06= Appropriate evaluation for secondary causes}}
  and admission | A06= Appropriate evaluation for secondary causes}}
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{{Family tree | | | | B01 | | | |B01= No}}
{{Family tree | | | | B01 | | | |B01= No}}
{{Family tree | | | | |!| | | | | }}
{{Family tree | | | | |!| | | | | }}
{{Family tree | | | | B01 | | | |B01= 1. Are headaches recurrent that interfere with work, family or social function?<br> 2. Do headaches last at least 4 h if untreated?
{{Family tree | | | | B01 | | | |B01= 1. Are headaches [[recurrent]] that interfere with work, family or social function?<br> 2. Do headaches last at least 4 h if untreated?


}}
}}
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}}
}}
{{Family tree | | | | |!| | | | | }}
{{Family tree | | | | |!| | | | | }}
{{Family tree | | | | B01 | | | |B01= Diagnose migraine}}
{{Family tree | | | | B01 | | | |B01= Diagnose [[migraine]]}}
{{Family tree | | | | |!| | | | | }}
{{Family tree | | | | |!| | | | | }}
{{Family tree | | | | B01 | | | |B01= Evaluate yellow flags<br>•  Drug seeking with underlying chronic pain
{{Family tree | | | | B01 | | | |B01= Evaluate yellow flags<br>•  [[Drug]] seeking with underlying [[chronic pain]]
  <br>• Recurrent ED visits without appropriate outpatient management/ PCP follow-up or <br>• OARRS report shows opiate use ± multisourcing}}
  <br>• Recurrent ED visits without appropriate outpatient management/ PCP follow-up or <br>• OARRS report shows [[opiate]] use ± multisourcing}}
{{Family tree | | | | |!| | | | | }}
{{Family tree | | | | |!| | | | | }}
{{Family tree | | | | B01 | | | |B01= Assess for treatment contraindications: pregnancy, allergies,  
{{Family tree | | | | B01 | | | |B01= Assess for treatment contraindications: [[pregnancy]], [[allergies]],  
comorbid conditions
comorbid conditions
}}
}}
{{Family tree | | | | |!| | | | | }}
{{Family tree | | | | |!| | | | | }}
{{Family tree | | | | A01 | | | |A01= Avoid opioids}}
{{Family tree | | | | A01 | | | |A01= Avoid [[opioids]]}}
{{Family tree | | | | |!| | | | | }}
{{Family tree | | | | |!| | | | | }}
{{Family tree | | | | B01 | | | |B01= Treat with<br>
{{Family tree | | | | B01 | | | |B01= Treat with<br>
  Ketorolac 30 mg IVP or 30-60 mg IM<br> +<br> Metoclopramide 10 mg IVP over 2 min or Ondansetron 8 mg IVP<br> +<br>Diphenhydramine 25-50 mg<br> +<br> IVP IV fl uids for hydration
  Ketorolac 30 mg IVP or 30-60 mg IM<br> +<br> [[Metoclopramide]] 10 mg IVP over 2 min or [[Ondansetron]] 8 mg IVP<br> +<br>[[Diphenhydramine]] 25-50 mg<br> +<br> IVP IV fl uids for [[hydration]]
}}
}}
{{Family tree | | | | |!| | | | | }}
{{Family tree | | | | |!| | | | | }}
{{Family tree | | | | A01 |-| A02 |-| A03 | | | |A01= More than 50% relief? | A02= Yes| A03= Discharge patient<br> 1. Disposition  
{{Family tree | | | | A01 |-| A02 |-| A03 | | | |A01= More than 50% relief? | A02= Yes| A03= Discharge patient<br> 1. Disposition  
<br> 2. No opiate scripts <br> 3. If responsive to ketorolac, discharge with toradol script 10 mg PO tid for up to 5 days
<br> 2. No opiate scripts <br> 3. If responsive to [[ketorolac]], discharge with toradol script 10 mg PO tid for up to 5 days
  <br> 4. If response to sumatriptan, discharge with script <br> 5. If response to DHE, discharge with Migranal nasal spray script or DHE sc script <br> 6. If responsive to valproate, valproic taper 250 tid for 3 d, 250 bid for3 d, 250 qd for 3 d, then stop <br> 7. Discharge with PCP follow-up  
  <br> 4. If response to [[sumatriptan]], discharge with script <br> 5. If response to [[DHE]], discharge with Migranal nasal spray script or DHE sc script <br> 6. If responsive to [[valproate]], [[valproic]] taper 250 tid for 3 d, 250 bid for3 d, 250 qd for 3 d, then stop <br> 7. Discharge with [[PCP]] follow-up  
  <br> 8. If no PCP, refer to PCP }}
  <br> 8. If no PCP, refer to PCP }}
{{Family tree | | | | |!| | | | | }}
{{Family tree | | | | |!| | | | | }}
{{Family tree | | | | B01 | | | |B01= No}}
{{Family tree | | | | B01 | | | |B01= No}}
{{Family tree | | | | |!| | | | | }}
{{Family tree | | | | |!| | | | | }}
{{Family tree | | | | B01 | | | |B01= Treat with<br> Sumatriptan: 6 mg sc — may repeat in 1 h if no response. (Max dose 12 mg in 24-h period <br> OR<br> 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  
{{Family tree | | | | B01 | | | |B01= Treat with<br> [[Sumatriptan]]: 6 mg sc — may repeat in 1 h if no response. (Max dose 12 mg in 24-h period <br> OR<br> [[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 1 mg sc. or choose an [[antiemetic]]: [[Prochlorperazine]] 10 mg IVP over 30 sec q2-4h prn
<br> OR<br> Metoclopramide: 10 mg IVP over 2 min  
<br> OR<br> [[Metoclopramide]]: 10 mg IVP over 2 min  
<br> OR<br> Ondansetron: 4-8 mg IVP over 30 sec }}
<br> OR<br> [[Ondansetron]]: 4-8 mg IVP over 30 sec }}
{{Family tree | | | | |!| | | | | }}
{{Family tree | | | | |!| | | | | }}
{{Family tree | | | | B01 | | | |B01= More than 50% relief?
{{Family tree | | | | B01 | | | |B01= More than 50% relief?
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==Do's==
==Do's==


* 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]].
* 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]].<ref name="pmid30083630">{{cite journal |vauthors=Montemayor ET, Long B, Pfaff JA, Moore GP |title=Patient with a Subarachnoid Headache |journal=Clin Pract Cases Emerg Med |volume=2 |issue=3 |pages=193–196 |date=August 2018 |pmid=30083630 |pmc=6075496 |doi=10.5811/cpcem.2018.5.38417 |url=}}</ref>
* Distinguish [[migraine]] from [[meningitis]] if in addition of [[Photophobia|photophobi]]<nowiki/>a and [[phonophobia]], [[Neck stiffness|neck stiffnes]]<nowiki/>s and fever coexist.
* Distinguish [[migraine]] from [[meningitis]] if in addition of [[Photophobia|photophobi]]<nowiki/>a and [[phonophobia]], [[Neck stiffness|neck stiffnes]]<nowiki/>s and fever coexist.<ref name="urlMigraine and Meningitis | JAMA Neurology | JAMA Network">{{cite web |url=https://jamanetwork.com/journals/jamaneurology/article-abstract/579362 |title=Migraine and Meningitis &#124; JAMA Neurology &#124; JAMA Network |format= |work= |accessdate=}}</ref>
* Perform an [[MRI]] or [[CT scan]] of the [[head]], if [[intracranial hypertension]] is suspected. Morning predominant headache accompanied by [[vomiting]] supports the [[diagnosis]] of [[Brain tumor|intracranial tumors]].
* Perform an [[MRI]] or [[CT scan]] of the [[head]], if [[intracranial hypertension]] is suspected. Morning predominant headache accompanied by [[vomiting]] supports the [[diagnosis]] of [[Brain tumor|intracranial tumors]].<ref name="pmid29071043">{{cite journal |vauthors=Sina F, Razmeh S, Habibzadeh N, Zavari A, Nabovvati M |title=Migraine headache in patients with idiopathic intracranial hypertension |journal=Neurol Int |volume=9 |issue=3 |pages=7280 |date=August 2017 |pmid=29071043 |pmc=5641834 |doi=10.4081/or.2017.7280 |url=}}</ref>


==Don'ts==
==Don'ts==


* Do not administer [[Drospirenone and Ethinyl estradiol]] or [[Norelgestromin and Ethinyl Estradiol]] in patients older than 35.
* Do not administer [[Drospirenone and Ethinyl estradiol]] or [[Norelgestromin and Ethinyl Estradiol]] in patients older than 35.<ref name="urlEthinyl estradiol and norelgestromin (transdermal) Uses, Side Effects & Warnings - Drugs.com">{{cite web |url=https://www.drugs.com/mtm/ethinyl-estradiol-and-norelgestromin-transdermal.html |title=Ethinyl estradiol and norelgestromin (transdermal) Uses, Side Effects & Warnings - Drugs.com |format= |work= |accessdate=}}</ref>
* Do not administer [[Non-steroidal anti-inflammatory drug|NSAIDs]] more than 15 days straight do to possible [[rebound headache]].
* Do not administer [[Non-steroidal anti-inflammatory drug|NSAIDs]] more than 15 days straight do to possible [[rebound headache]].<ref name="pmid29262094">{{cite journal |vauthors=Aleksenko D, Maini K, Sánchez-Manso JC |title= |journal= |volume= |issue= |pages= |date= |pmid=29262094 |doi= |url=}}</ref>


==References==
==References==
{{Reflist|2}} {{WS}} {{WH}}
{{Reflist|2}} {{WS}} {{WH}}
<references />
<references />

Revision as of 15:57, 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.[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.[5][6] 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

  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. 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 |month= ignored (help)
  6. 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 |month= ignored (help)
  7. "An Algorithm of Migraine Treatment - touchNEUROLOGY".
  8. "www.painmedicinenews.com".
  9. 9.0 9.1 "Migraine and Meningitis | JAMA Neurology | JAMA Network".
  10. 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.
  11. 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.
  12. "Ethinyl estradiol and norelgestromin (transdermal) Uses, Side Effects & Warnings - Drugs.com".
  13. Aleksenko D, Maini K, Sánchez-Manso JC. PMID 29262094. Missing or empty |title= (help)

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