Migraine headache

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

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)[3]
    • 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
    • Consider dexamethasone 10mg IV x 1 to prevent recurrence 48-72 hrs post-ED discharge, if history of recurrent headaches (NNT = 10)[4]

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]
  • Sumatriptan most effective within 6 hours of headache onset[8]
    • 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
    • Contraindications to triptans include CV disease, uncontrolled HTN, pregnancy
  • Consider dexamethasone 10 mg IV single dose to prevent recurrence 48-72 hrs post-ED discharge, if history of recurrent headaches[9]
  • 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[10]
  • Valproate sodium 500-1000 mg IV in 50 mL of NS over 20 minutes (alternatively 10 mg/kg IV, pediatrics, max 500 mg)[11]
  • Droperidol IV/IM 1.25-2.75 mg, plus or minus diphenhydramine for extrapyramidal symptoms[12]
    • 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[13]
  • Consider 5-10 mg PO olanzapine (Zyprexa, Zydis) for prochlorperazine allergy[14][15]
    • 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[16]
  • Ketamine IM/IV at subdissociative dosages, with risk stratification for potential ICP increase, though now widely considered a myth[17]
  • 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[18]
  • 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 [19]
  • Greater occipital nerve block
    • For refractory occipital migraine, cluster headache, occipital neuralgia, cervicogenic headache, or migraine with occipital nerve irritation or tenderness [20]
    • Typically, a local anesthetic such as lidocaine (1-2%) or bupivacaine (0.5%) (or a combination of the two) is injected. Lidocaine has a quicker onset, while bupivacaine has a longer lasting effect. Total volume injected is 2-4cc per nerve block.
    • Identify the location of the greater occipital nerve via one of 3 methods:
    • Palpate the occipital artery pulse about 2cm lateral to the occipital protuberance. The greater occipital nerve is just medial to the occipital artery
    • Alternatively, palpate the occipital protuberance and the mastoid process (on side of interest). Measure 1/3 the distance between the two points starting from the occipital protuberance. Stay just superior to the superior nuchal line to remain over the cranium.
    • Alternatively, identify the point of maximal tenderness in the general region as defined above that may elicit paresthesia in the occipital nerve distribution when palpated
    • Clean the site of injection. Using a 23-25G needle, insert the needle at a 90-degree angle toward the occiput until a bony endpoint is obtained. Aspirate to avoid intravascular injection and to prevent injection into CSF. Inject 1cc at the GON, 1cc medial to the nerve, and 1cc lateral to the nerve.
  • Severe, intractable status migrainosus may benefit from off-label IV propofol[21][22][23]
    • 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[24]
    • 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[25]

Disposition

  • Outpatient

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. 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.
  9. 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
  10. Demirkaya S et al. Efficacy of intravenous magnesium sulfate in the treatment of acute migraine attacks. Headache. 2001 Feb;41(2):171-7.
  11. Shahien R et al. Intravenous sodium valproate aborts migraine headaches rapidly. Acta Neurol Scand. 2011 Apr;123(4):257-65.
  12. Thomas MC et al. Droperidol for the treatment of acute migraine headaches. Ann Pharmacother. 2015 Feb;49(2):233-40.
  13. 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.
  14. Silberstein SD et al. Olanzapine in the treatment of refractory migraine and chronic daily headache. Headache. 2002 Jun;42(6):515-8.
  15. Rozen TD. Olanzapine as an abortive agent for cluster headache. Headache. 2001;41(8):813-816.
  16. Farkas J. PulmCrit. PulmCrit- Intravenous olanzapine: Faster than IM olanzapine, safer than IV haloperidol? Feb 1, 2016. http://emcrit.org/pulmcrit/intravenous-olanzapine-haloperidol/
  17. 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.
  18. 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.
  19. https://www.aliem.com/2017/03/trick-sphenopalatine-ganglion-block-primary-headaches/
  20. https://www.nuemblog.com/blog/occipital-nerve-block
  21. The Efficacy of Propofol vs. Subcutaneous Sumatriptan for Treatment of Acute Migraine Headaches in the Emergency Department: A DBCT. Pain Prac. 2014 Jul 12.
  22. Fortuitous Finding – IV Propofol: Unique Effectiveness in Treating Intractable Migraine. Krusz, John C. Headache 2000;40:224-230.
  23. 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.
  24. Soleimanpour et al. BMC Neurology 2012. 12:114. 90 pts in ED w/ Migraine.
  25. 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.