Migraine resident survival guide

Migraine Resident Survival Guide Microchapters
Overview
Causes
Treatment
Do's
Don'ts

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Moises Romo, M.D., Fahimeh Shojaei, M.D.

Synonyms and Keywords: approach to migraine, migraine workup, migraine management, migraine treatment

Overview

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.

Causes

Life-threatening causes

• 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.

Common Causes

• 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
• Alcohol
• Caffeine
• 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

Diagnosis

Shown below is an algorithm summarizing the diagnosis of Headache according the American Academy of Neurology guidelines:

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 •Papilledema •Headache subsequent to head trauma

Yes

Refer and investigate

Possible indicators of secondary headache •Unexplained focal signs •Atypical headaches •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)

Yes

No

Migraine •Acute medications •Monitor for medication overuse •Prophylactic medication if: -Headache >3 d/mo and acute medications are not effective OR -Headache >8 d/mo (risk of overuse) OR -Disability despite acute medication

Headache with >2 of the following: •Nausea •Light sensitivity •Interference with activities Practice points: •Migraine has been historically underdiagnosed •Considere migraine diagnosis for recurring "sinus" headaches

Yes Migraine

Medication overuse Assess •Ergots, triptans, combination analgesics, or codeine or other opioids >10 d/mo OR •Acetaminophen or NSAIDs >15 d/mo Manage •Educate patient •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 •Acute medications •Monitor for medication overuse •Prophylactic medication disability despite medication

Headache with no nausea but >2 of the following: •Bilateral headache •Nonpulsating pain •Not worsened by activity

Yes Tension type headache

No

Uncommon headache syndromes

All of the following: •Frequent headache •Severe •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) •Continuous •Dramatically responsive to indomethacin

Headache continuous side onset

Yes

Yes

Yes

Cluster headache or another trigeminal autonomic cephalalgia •Management primarly pharmacologic •Acute medication •Prophylactic medication •Early specialist referral recommended

Hemicrania continua •Specialist referral

New daily persistent headache •Specialist referral

Treatment

Shown below is an algorithm summarizing the treatment of migraine according the American Academy of Neurology guidelines:

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

• 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.

Don'ts

• 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.