Migraine headache

Background[1]

  • Female-to-male ratio of 3:1
  • Tend to be familial
    • heritability estimated to be approximately 42%
  • Pathogenesis is thought to involve the trigeminovascular system, which when activated results in parasympathetic dilation of intracranial arteries.
  • Migraine without aura most common (~80%)[2]

Definition: Migraine Headache without Aura[3]

  • 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

Definition: Migraine Headache with Aura

  • At least two attacks fulfilling criteria A and B
  • Criteria A: One or more of the following fully reversible aura symptoms:
    • visual
    • sensory
    • speech and/or language
    • motor
    • brainstem
    • retinal
  • Criteria B: At least three of the following six characteristics:
    • at least one aura symptom spreads gradually over ≥5 minutes
    • two or more aura symptoms occur in succession
    • each individual aura symptom lasts 5-60 minutes
    • at least one aura symptom is unilateral
    • at least one aura symptom is positive
    • the aura is accompanied, or followed within 60 minutes, by headache
  • Not better accounted for by another ICHD-3 diagnosis.

Clinical Features

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

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

Basilar-type migraine may be associated with fully reversible dysarthria, vertigo, tinnitus, decreased hearing, double vision or ataxia

Differential Diagnosis

Headache

Common

Killers

Maimers

Others

Aseptic Meningitis

Evaluation

Workup

  • Consider pregnancy test (for medication selection)

Diagnosis

  • Diagnosis is normally clinical
    • Make sure you considered other causes of emergent headache

Management

  • 1st line: Prochlorperazine (compazine) 10mg IV (+/- diphenhydramine 12.5mg IV)[5]
    • Most effective therapy
  • 2nd line:
    • Metoclopramide (reglan) 10mg IV
    • DHE 1mg IV over 3min
    • Triptans
      • Contraindications: cardiovascular disease, use of DHE in previous 24hrs
  • Ketorolac
  • Steroids
    • Dexamethasone to prevent recurrence 48-72 hours post-ED discharge, if history of migraines and recurrent headaches[6]
      • 10 mg IV single dose is commonly accepted regimen, 4 mg IV dose was shown to be as efficacious in a follow up study. [7]

Non-specific Headache

If known, treat specific headache type; avoid opioid medications if at all possible

  • 1st line: prochlorperazine (compazine) 10 mg IV (+/- diphenhydramine 25-50 mg IV) + 1 L IVF bolus
    • Place prochlorperazine in IV bag to reduce chances of side effects from rapid administration
    • Alternative metoclopramide 10 mg IV[8] (diphenhydramine addition shows no clinical benifit[9])
  • Acetaminophen IV or PO, 325-1000 mg
  • Ketorolac 10-30 mg IV (30-60mg IM)
    • Lower doses are shown to be just as effective[10]
  • Sumatriptan most effective within 6 hours of headache onset[11]
    • Serotonin 5HT1B/1D receptor agonist (e.g. sumatriptan)
    • 6 mg SQ or IM, may repeat dose x1 after 1 hour, max 12 mg / 24 hours
    • OR 100 mg PO, may repeat dose x1 after 2 hours, max 200 mg / 24 hours
    • OR 1-2 sprays IN (may repeat after 2 hours)
    • Contraindications to triptans include CV disease, uncontrolled HTN, pregnancy
  • Dexamethasone to prevent recurrence 48-72 hours post-ED discharge, if history of migraines and/or recurrent headaches[12]
    • 10 mg IV single dose is commonly accepted regimen, 4 mg IV dose was shown to be as efficacious in a follow up study. [13]

Other 2nd and 3rd Line Options

  • Magnesium 1-2 g IV over 30-60 minutes, low side effect profile, in treatment of acute migraine attacks[14]
  • Valproate sodium 500-1000 mg IV in 50 mL of NS over 20 minutes (alternatively 10 mg/kg IV, pediatrics, max 500 mg)[15]
  • Droperidol IV/IM 1.25-2.75 mg, plus or minus diphenhydramine for extrapyramidal symptoms[16]
    • 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[17]
  • Consider 5-10 mg PO olanzapine (Zyprexa, Zydis) for prochlorperazine allergy[18][19]
    • Particularly useful in psych patients with mania, BPD, psychosis
    • IV olanzapine may be as safe or safer than IM, with faster onset[20]
  • Ketamine IM/IV at subdissociative dosages, with risk stratification for potential ICP increase, though now widely considered a myth[21]
  • 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[22]
  • Sphenopalatine ganglion block
    • Great for patients without an IV
    • 10 cm cotton-tipped applicator soaked in lidocaine or bupivicaine and inserted nasally along the superior border of the middle turbinate and left for 5-10 minutes [23]
  • Consider greater occipital nerve block
    • For refractory occipital migraine, cluster headache, occipital neuralgia, cervicogenic headache, or migraine with occipital nerve irritation or tenderness [24]
  • Severe, intractable status migrainosus may benefit from off-label IV propofol[25][26][27]
    • 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[28]
    • 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
  • Lifestyle changes (avoiding caffeine, smoking and food triggers)
  • 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[29]

Disposition

  • Outpatient

See Also

References

  1. ↑ Ashina, Messoud. Migraine. The New England Journal of Medicine. 2020;383(19): 1866-1876
  2. ↑ Russi CS, Walker L. Headache. In: Walls RM, Hockberger RS, Gausche-Hill M, et al., eds. Rosen’s Emergency Medicine: Concepts and Clinical Practice. 9th ed. Philadelphia, PA: Elsevier Saunders; 2018:(Ch) 17:153–159.
  3. ↑ International Headache Society Diagnostic Criteria
  4. ↑ Detsky et. al, JAMA '06 Does this Patient with a Headache have a Migraine or need Neuroimaging?
  5. ↑ Coppola et al, Annals of Emergency Medicine, Nov 1995. Randomized, Placebo-Controlled Evaluation of Prochlorperazine Versus Metoclopramide for Emergency Department Treatment of Migraine Headaches.
  6. ↑ Colman et al Parenteral dexamethasone for acute severe migraine headache: meta-analysis of randomised controlled trials for preventing recurrence. BMJ 2008 Jun.;336(7657):1359–1361
  7. ↑ Friedman BW, Solorzano C, Kessler BD, Martorello K, Lutz CL, Feliciano C, Adler N, Moss H, Cain D, Irizarry E. Randomized Trial Comparing Low- vs High-Dose IV Dexamethasone for Patients With Moderate to Severe Migraine. Neurology. 2023 Oct 3;101(14):e1448-e1454.
  8. ↑ Metoclopramide for Pain and Nausea in Patients with Migraine. Am Fam Physician. 2005 May 1;71(9):1770.
  9. ↑ 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.
  10. ↑ 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.
  11. ↑ Efficacy and safety of intravenous acetylsalicylic acid lysinate compared to subcutaneous sumatriptan and parenteral placebo in the acute treatment of migraine. A double-blind, double-dummy, randomized, multicenter, parallel group study. The ASASUMAMIG Study Group. Diener HC. Cephalalgia. 1999 Jul; 19(6):581-8; discussion 542.
  12. ↑ Colman et al Parenteral dexamethasone for acute severe migraine headache: meta-analysis of randomised controlled trials for preventing recurrence. BMJ 2008 Jun.;336(7657):1359–1361
  13. ↑ Friedman BW, Solorzano C, Kessler BD, Martorello K, Lutz CL, Feliciano C, Adler N, Moss H, Cain D, Irizarry E. Randomized Trial Comparing Low- vs High-Dose IV Dexamethasone for Patients With Moderate to Severe Migraine. Neurology. 2023 Oct 3;101(14):e1448-e1454.
  14. ↑ Demirkaya S et al. Efficacy of intravenous magnesium sulfate in the treatment of acute migraine attacks. Headache. 2001 Feb;41(2):171-7.
  15. ↑ Shahien R et al. Intravenous sodium valproate aborts migraine headaches rapidly. Acta Neurol Scand. 2011 Apr;123(4):257-65.
  16. ↑ Thomas MC et al. Droperidol for the treatment of acute migraine headaches. Ann Pharmacother. 2015 Feb;49(2):233-40.
  17. ↑ 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.
  18. ↑ Silberstein SD et al. Olanzapine in the treatment of refractory migraine and chronic daily headache. Headache. 2002 Jun;42(6):515-8.
  19. ↑ Rozen TD. Olanzapine as an abortive agent for cluster headache. Headache. 2001;41(8):813-816.
  20. ↑ Farkas J. PulmCrit. PulmCrit- Intravenous olanzapine: Faster than IM olanzapine, safer than IV haloperidol? Feb 1, 2016. http://emcrit.org/pulmcrit/intravenous-olanzapine-haloperidol/
  21. ↑ 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.
  22. ↑ 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.
  23. ↑ https://www.aliem.com/2017/03/trick-sphenopalatine-ganglion-block-primary-headaches/
  24. ↑ https://www.nuemblog.com/blog/occipital-nerve-block
  25. ↑ The Efficacy of Propofol vs. Subcutaneous Sumatriptan for Treatment of Acute Migraine Headaches in the Emergency Department: A DBCT. Pain Prac. 2014 Jul 12.
  26. ↑ Fortuitous Finding – IV Propofol: Unique Effectiveness in Treating Intractable Migraine. Krusz, John C. Headache 2000;40:224-230.
  27. ↑ 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.
  28. ↑ Soleimanpour et al. BMC Neurology 2012. 12:114. 90 pts in ED w/ Migraine.
  29. ↑ 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.
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