Migraine headache

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Background

Definition: Migraine Headache without Aura[1]

  • At least 5 attacks of headache fulfilling the following criteria:
    • headache attacks lasting 4–72 hr (untreated or unsuccessfully treated) (>1 h for children)
    • headache has at least 2 of the following characteristics:
      • Unilateral location
      • Pulsating quality
      • Moderate or severe pain intensity
      • Aggravation by or causing avoidance of routine physical activity
    • During headache at least one of the following occurs:
      • Nausea and/or vomiting
      • Photophobia and phonophobia (may be inferred from behavior)
    • Not attributed to another disorder

Clinical Features

If at least 4 of the following "POUNDing" features, LR of migraine is 24[2]

  • Pulsatile quality
  • Onset/duration of 4-72 hours
  • Unilateral
  • Nausea or vomiting
  • Disabling in quality

Differential Diagnosis

Headache

Common

Killers

Maimers

Others

Aseptic Meningitis

Evaluation

  • Consider other causes of emergent headache
  • Diagnosis is normally clinical

Management

Non-specific Headache

Treat specific headache type, if known

  • 1st line: prochlorperazine (compazine) 10 mg IV (+/- diphenhydramine 25-50 mg IV) + 1 L normal saline IV bolus
    • Place prochlorperazine in IV bag to reduce chances of side effects from rapid administration
    • Alternative metoclopramide 10 mg IV[5] (diphenhydramine addition shows no clinical benifit[6])
  • Acetaminophen IV or PO, 325-1000 mg
  • Ketorolac 30 mg IV
    • Lower doses are shown to be just as effective[7]
  • Consider dexamethasone 10 mg IV single dose to prevent recurrence 48-72 hrs post-ED discharge, if history of recurrent headaches[8]
  • Avoid opioid medications if possible

Other 2nd and 3rd Line Medications

  • Magnesium 1 g IV over 30-60 minutes, low side effect profile, in treatment of acute migraine attacks[9]
  • Valproate sodium 500-1000 mg IV in 50 mL of NS over 20 minutes (alternatively 10 mg/kg IV, pediatrics, max 500 mg)[10]
  • Droperidol IV/IM 1.25-2.75 mg, plus or minus diphenhydramine for extrapyramidal symptoms[11]
    • Perform EKG monitoring for patients at risk of QTc prolongation
    • Do not give to patients who take already multiple QT prolonging drugs
  • Consider haloperidol IV 5 mg in IVF bolus with diphenhydramine to prevent need for rescue medications[12]
  • Consider 5-10 mg PO olanzapine (Zyprexa, Zydis) for prochlorperazine allergy[13][14]
    • While less extrapyramidal symptoms than typical antipsychotics, beware QT prolongation
    • Particularly useful in psych patients with mania, BPD, psychosis
    • IV olanzapine may be as safe or safer than IM, with faster onset[15]
  • Ketamine IM/IV at subdissociative dosages, with risk stratification for potential ICP increase, though now widely considered a myth[16]
  • Dexamethasone 10 mg IV
  • Cervical spine injection with IM injection of 1.5 mL of 0.5% bupivacaine (plus or minus methylprednisolone acetate) bilaterally to the sixth or seventh spinous process[17]
  • Severe, intractable status migrainosus may benefit from off-label IV propofol[18][19][20]
    • Requires procedural sedation monitoring and possible IV fluid resuscitation, respiratory decompensation intervention
    • Propofol 0.5 mg/kg bolus, then 0.25 mg/kg every 10 minutes for 1 hour
    • Less aggressive regimens include propofol 10 mg q5-10 min to ma of 80 mg[21]
    • Consider using 1 mL 2% lidocaine added to every 10 mL of 10 mg/mL concentration propofol
    • Average dosage required ~100-125 mg

Migraine Prophylaxis

  • Typically not the role or responsibility of the EP
  • If inclined to give Rx, give very short supply and ensure proper follow up
  • Consider drug side effects, interactions, cormorbidities
  • American Academy of Neurology and American Headache Society level A drug options, starting dosages[22]
    • Valproate/divalproex 250 mg q12
    • Metoprolol 25 mg q12
    • Propanolol 30 mg q8
    • Timolol 10 mg q12
    • Topiramate 25 mg QHS x1, then 25 mg q12

See Also

References

  1. International Headache Society Diagnostic Criteria
  2. Detsky et. al, JAMA '06 Does this Patient with a Headache have a Migraine or need Neuroimaging?
  3. Coppola et al, Annals of Emergency Medicine, Nov 1995. Randomized, Placebo-Controlled Evaluation of Prochlorperazine Versus Metoclopramide for Emergency Department Treatment of Migraine Headaches.
  4. Colman et al Paraenteral dexamethasone for acute severe migraine headache: meta-analysis of randomised controlled trials for preventing recurrence. BMJ 2008 Jun.;336(7657):1359–1361
  5. Metoclopramide for Pain and Nausea in Patients with Migraine. Am Fam Physician. 2005 May 1;71(9):1770.
  6. Friedman BW, et al. Diphenhydramine as Adjuvant Therapy for Acute Migraine: An Emergency Department-Based Randomized Clinical Trial. Annals of EM. January 2016. 67(1):32-39.
  7. Brown CR, Moodie JE, Wild VM, Bynum LJ. Comparison of intravenous ketorolac tromethamine and morphine sulfate in the treatment of postoperative pain. Pharmacotherapy. 1990;10(6Patient 2):116S-121S.
  8. Colman et al Paraenteral dexamethasone for acute severe migraine headache: meta-analysis of randomised controlled trials for preventing recurrence. BMJ 2008 Jun.;336(7657):1359–1361
  9. Demirkaya S et al. Efficacy of intravenous magnesium sulfate in the treatment of acute migraine attacks. Headache. 2001 Feb;41(2):171-7.
  10. Shahien R et al. Intravenous sodium valproate aborts migraine headaches rapidly. Acta Neurol Scand. 2011 Apr;123(4):257-65.
  11. Thomas MC et al. Droperidol for the treatment of acute migraine headaches. Ann Pharmacother. 2015 Feb;49(2):233-40.
  12. Gaffigan ME et al. A Randomized Controlled Trial of Intravenous Haloperidol vs. Intravenous Metoclopramide for Acute Migraine Therapy in the Emergency Department. J Emerg Med. 2015 Sep;49(3):326-34.
  13. Silberstein SD et al. Olanzapine in the treatment of refractory migraine and chronic daily headache. Headache. 2002 Jun;42(6):515-8.
  14. Rozen TD. Olanzapine as an abortive agent for cluster headache. Headache. 2001;41(8):813-816.
  15. Farkas J. PulmCrit. PulmCrit- Intravenous olanzapine: Faster than IM olanzapine, safer than IV haloperidol? Feb 1, 2016. http://emcrit.org/pulmcrit/intravenous-olanzapine-haloperidol/
  16. Sin B et al. The use of subdissociative-dose ketamine for acute pain in the emergency department. Acad Emerg Med. 2015 Mar;22(3):251-7.
  17. Mellick LB et al. Treatment of headaches in the ED with lower cervical intramuscular bupivacaine injections: a 1-year retrospective review of 417 patients. Headache. 2006 Oct;46(9):1441-9.
  18. The Efficacy of Propofol vs. Subcutaneous Sumatriptan for Treatment of Acute Migraine Headaches in the Emergency Department: A DBCT. Pain Prac. 2014 Jul 12.
  19. Fortuitous Finding – IV Propofol: Unique Effectiveness in Treating Intractable Migraine. Krusz, John C. Headache 2000;40:224-230.
  20. Simmonds MK. The effect of single-dose porpofol injection on pain and quality of life in chronic daily headaches: a RDBCT. Anesth Analg. 2009 3Dec;109(6):1972-80.
  21. Soleimanpour et al. BMC Neurology 2012. 12:114. 90 pts in ED w/ Migraine.
  22. Loder E et al. The 2012 AHS/AAN Guidelines for Prevention of Episodic Migraine: A Summary and Comparison With Other Recent Clinical Practice Guidelines. 2012 American Headache Society. Headache 2012;52:930-945.