Author:
Benjamin W.Friedman
Description
- Chronic episodic headache disorder
- Neurovascular pathophysiology:
- Aberrant trigeminal nerve activation
- Activation of nociceptive pathways within brainstem
- Vascular dilation is reactive rather than causative
- No longer considered primarily a vascular headache
- Disordered sensory processing and autonomic dysfunction
- Cortical spreading depression underlies aura
- 1.2 million ED visits per year
- Causes majority of ED headache visits
- 3× as common in women
- Prevalence peaks in fourth decade of life
- Established criteria for migraine without aura:
- A. 5 attacks fulfilling criteria B, C, D, E
- B. Attack lasts 4-72 hr
- C. Headache has 2 of the following:
- 1. Unilateral location
- 2. Pulsating
- 3. Moderate to severe pain (impairs activities)
- 4. Aggravation by or avoidance of physical activity
- D. During headache, nausea, or vomiting and /or photophobia + phonophobia
- E. Not attributable to other cause
- Migraine with aura:
- Less common
- Classically, reversible neurologic symptoms that precede headache
- Some patients report aura at the same time or after the headache
- Rarer subtypes of migraine include:
- Basilar type migraine:
- Dysarthria, vertigo, ataxia, diplopia, or decreased level of consciousness
- Hemiplegic migraine:
- Full reversible motor weakness
- Retinal migraine:
- Repeated attacks of monocular visual disturbance
Pediatric Considerations |
- More commonly bilateral pain and shorter duration of headache
- Associated symptoms may be difficult to elicit and can be inferred from behavior
- Cyclical vomiting syndrome associated with migraine
- High placebo response
|
Etiology
Genetic disorder with variable penetrance, influenced by the environmental factors
Signs and Symptoms
History
- May be precipitated by food, alcohol, viral illness, or stress
- Menstrual migraine may precede menstruation by several days
- Prodrome also precedes migraine by several days:
- May consist of cognitive or emotional alterations, yawning, drowsiness
- Aura precedes migraine by 1 hr:
- Most commonly consists of visual or sensory disturbances:
- Scintillating scotoma:
- Often a flickering lights
- Varying degrees of visual impairment
- Fortification spectra:
- An arc of light which may have a zigzag pattern
- Numbness or tingling
- Headache typically unilateral, throbbing
- Sufficiently intense to impair activity
- Can be bilateral
- Usually associated with:
- Osmophobia (olfactory sensitivity)
- Photophobia
- Phonophobia
- Nausea, or vomiting
- Usually gradual onset
- History often reflects similar headache previously
Physical Exam
- Allodynia (sensitivity to normally nonnoxious stimuli) may be present and signifies more refractory migraine
- Physical exam should otherwise be normal
- Physical exam in atypical cases should include exam of fundi and assessment of visual fields
- Elevated blood pressure does not exclude migraine as diagnosis
- Sinus tenderness does not exclude migraine as diagnosis
Essential Workup
- An accurate history and physical exam confirm the diagnosis
- Patients with new headache syndrome may require workup including imaging and spinal fluid analysis
Diagnostic Tests & Interpretation
Diagnostic Procedures/Surgery
None required
Differential Diagnosis
- Cluster headache
- Medication overuse headache
- Tension-type headache
- Allergic or viral rhinosinusitis
- Idiopathic intracranial hypertension (pseudotumor cerebri)
- Reversible cerebral vasoconstriction syndrome
Prehospital
- Allow patients with migraine headache to be in a calm, dark environment
- Oxygen may be beneficial
Initial Stabilization/Therapy
- Exclude secondary causes of headache
- Rapid and effective analgesia
ED Treatment/Procedures
- Detailed history will exclude secondary cause of headache in most patients
- Provide analgesia without relying upon opioid analgesics
- IV saline hydration not necessarily helpful absent clinical signs of dehydration
- Provide patient with diagnosis - “You have a migraine,” education about trigger avoidance
- Frequent visitors who insist upon treatment with opioids are difficult to manage during a busy shift. Treatment plans for these patients can be developed by interdisciplinary committees and then applied uniformly by all emergency providers
Medication
- Abortive therapy in ED:
- Dopamine antagonists:
- Prochlorperazine 10 mg IV coadministered with diphenhydramine 25 mg IV to prevent akathisia
- Haloperidol 5 mg IV coadministered with diphenhydramine 25 mg IV to prevent akathisia
- Metoclopramide 10 mg IV
- Triptans:
- Sumatriptan: 6 mg SC (avoid if cardiac risk factors)
- Eletriptan 40 mg PO
- Ergot alkaloids:
- Dihydroergotamine: 1 mg IV, coadministered with an antiemetic (avoid if cardiac risk factors; avoid if on macrolide or antiretrovirals)
- Nonsteroidals:
- Corticosteroids:
- Antiseizure medications:
Treatment Strategy
- Abortive therapy with antiemetics, triptans, DHE, or nonsteroidals
- Opioids only if no response to several of the above
- Corticosteroids to avoid post-ED headache recurrence
- Greater occipital nerve block with bupivacaine 0.5% may have a role in refractory patients
Disposition
Admission Criteria
- Persistent severe headache or focal neurologic deficits
- Intractable vomiting, electrolyte imbalance, or inability to take oral food or fluid
- Coexisting medication overuse headache
Discharge Criteria
- Headache relief
- Pathologic cause of headache excluded
Issues for Referral
Chronic migraine or frequent episodic migraine should be referred to a clinician with relevant expertise
Follow-up Recommendations
- Maintain headache diary to identify and avoid triggers
- Persistent primary care follow-up to identify an effective oral migraine therapeutic