Overview
Migraine Headache
Quick Reference
Critical Alerts
- Rule out secondary causes first: Thunderclap headache, worst headache of life, fever, focal deficits
- Triptans are first-line abortive therapy: If no contraindications
- IV fluids + IV antiemetic + IV NSAID = Effective ED cocktail
- Status migrainosus needs aggressive treatment: Lasting >72 hours
- Avoid opioids: Not first-line; risk of medication overuse headache
- Triptans contraindicated in CAD, uncontrolled HTN, prior stroke
Red Flags (SNOOP4)
| Letter | Red Flag |
|---|---|
| S | Systemic symptoms (fever, weight loss) or Systemic illness (cancer, HIV) |
| N | Neurological signs (focal deficits, papilledema, altered consciousness) |
| O | Onset sudden (thunderclap) |
| O | Older age (new headache >0 years) |
| P | Pattern change (worsening, different character) |
| P | Precipitated by Valsalva, exertion, position |
| P | Papilledema |
| P | Pregnancy or postpartum |
Emergency Treatments
| Treatment | Dose | Notes |
|---|---|---|
| IV fluids | NS 500-1000 mL | Rehydration |
| Metoclopramide | 10-20 mg IV | Antiemetic + analgesic properties |
| Prochlorperazine | 10 mg IV | Antiemetic; can cause akathisia |
| Ketorolac | 15-30 mg IV | NSAID |
| Sumatriptan | 6 mg SC or 100 mg PO | If no contraindications |
| Dexamethasone | 10 mg IV | Reduces recurrence |
| Diphenhydramine | 25-50 mg IV | For akathisia prevention with metoclopramide |
Definition
Overview
Migraine is a primary headache disorder characterized by recurrent, moderate-to-severe headaches often associated with nausea, vomiting, photophobia, and phonophobia. Some migraines are preceded by aura. ED management focuses on ruling out secondary causes, providing abortive therapy, and reducing recurrence.
Classification
By Aura:
| Type | Features |
|---|---|
| Migraine without aura | Most common (70-80%) |
| Migraine with aura | Visual, sensory, or language symptoms precede headache |
Other Types:
| Type | Features |
|---|---|
| Chronic migraine | ≥15 headache days/month for ≥3 months |
| Status migrainosus | Migraine >2 hours |
| Hemiplegic migraine | Aura includes motor weakness |
| Menstrual migraine | Occurs with menstruation |
Epidemiology
- Prevalence: 12% of adults (18% women, 6% men)
- Peak age: 25-55 years
- Female predominance: 3:1
- Leading cause of years lost to disability in young women
Etiology
Triggers:
| Category | Examples |
|---|---|
| Hormonal | Menstruation, oral contraceptives |
| Dietary | Alcohol (esp. red wine), caffeine, chocolate, aged cheeses, MSG |
| Sleep | Too little or too much sleep |
| Stress | Emotional or physical |
| Environmental | Bright lights, loud sounds, strong odors, weather changes |
| Medications | Vasodilators, hormones |
Pathophysiology
Mechanism
- Cortical spreading depression (in aura): Wave of neuronal depolarization
- Trigeminovascular activation: Trigeminal nerve releases CGRP, substance P
- Neurogenic inflammation: Vasodilation of meningeal vessels
- Central sensitization: Amplifies pain signals
Aura
- Visual (scintillating scotoma, fortification spectra) most common
- Sensory (paresthesias), language (aphasia), motor (hemiplegic)
- Typically precedes headache by 5-60 minutes
Clinical Presentation
Symptoms
Headache Features (POUND):
| Letter | Feature |
|---|---|
| P | Pulsating quality |
| O | One-day duration (4-72 hours) |
| U | Unilateral location |
| N | Nausea/vomiting |
| D | Disabling intensity |
Associated Symptoms:
History
Key Questions:
Physical Examination
General:
Neurological Exam:
In Classic Migraine:
Photophobia (light sensitivity)
Common presentation.
Phonophobia (sound sensitivity)
Common presentation.
Osmophobia (smell sensitivity)
Common presentation.
Visual aura (scintillating scotoma)
Common presentation.
Red Flags
Secondary Headache Warning Signs (SNOOP4)
| Finding | Concern | Action |
|---|---|---|
| Thunderclap onset | SAH, RCVS | CT head, LP if CT negative |
| Fever + headache | Meningitis | LP, antibiotics |
| Focal neurological deficits | Stroke, mass lesion | CT/MRI |
| Papilledema | Increased ICP | Imaging, LP |
| New headache >0 years | GCA, malignancy | ESR, imaging |
| Worst headache of life | SAH | CT, LP |
| Headache with exertion | SAH, mass | Imaging |
| Progressive pattern | Secondary cause | Imaging |
Differential Diagnosis
Other Causes of Headache
| Diagnosis | Features |
|---|---|
| Tension-type headache | Bilateral, pressing, mild-moderate, no nausea |
| Cluster headache | Unilateral, severe, periorbital, autonomic symptoms |
| SAH | Thunderclap, worst headache of life |
| Meningitis | Fever, neck stiffness, photophobia |
| Temporal arteritis (GCA) | Age >0, scalp tenderness, jaw claudication, vision changes |
| Intracranial mass | Progressive, focal deficits, worse in morning |
| Idiopathic intracranial hypertension | Papilledema, obesity, young woman |
| Medication overuse headache | Daily headaches, analgesic overuse |
Diagnostic Approach
Clinical Diagnosis
- Migraine is a clinical diagnosis
- Based on history and normal neurological exam
- Imaging for red flags only
Imaging
Not Routinely Indicated for Typical Migraine
Indications for CT/MRI:
| Indication | Imaging |
|---|---|
| Thunderclap headache | CT head → LP if CT negative |
| Focal neurological deficits | CT or MRI |
| New headache >0 years | CT or MRI |
| Papilledema | CT or MRI |
| Change in headache pattern | Consider imaging |
| Immunocompromised | CT or MRI |
Laboratory Studies
| Test | Indication |
|---|---|
| ESR, CRP | GCA suspected (>0 years) |
| LP | SAH (CT negative), meningitis |
| Pregnancy test | Women of childbearing age |
Treatment
Principles
- Rule out secondary causes: Red flags → Imaging/LP
- Rehydration: IV fluids
- Antiemetics: Relieve nausea and have analgesic properties
- NSAIDs or triptans: Abortive therapy
- Steroids: Reduce recurrence
- Avoid opioids: Not first-line
ED Migraine Cocktail
Common Regimen:
| Component | Dose | Notes |
|---|---|---|
| IV fluids | NS 500-1000 mL | Rehydration |
| Metoclopramide | 10-20 mg IV | Antiemetic + analgesic |
| + Diphenhydramine | 25-50 mg IV | Prevents akathisia |
| OR Prochlorperazine | 10 mg IV | Alternative antiemetic |
| Ketorolac | 15-30 mg IV | NSAID |
| Dexamethasone | 10 mg IV | Reduces recurrence |
If Refractory, Add Triptan:
| Agent | Dose |
|---|---|
| Sumatriptan | 6 mg SC or 100 mg PO |
Triptans
Mechanism: 5-HT1B/1D receptor agonists; vasoconstriction, reduce CGRP release
Options:
| Agent | Route | Dose |
|---|---|---|
| Sumatriptan | PO | 50-100 mg |
| Sumatriptan | SC | 6 mg |
| Sumatriptan | Nasal | 20 mg |
| Rizatriptan | PO | 10 mg |
| Zolmitriptan | PO | 2.5-5 mg |
Contraindications:
- Coronary artery disease
- Prior stroke or TIA
- Uncontrolled hypertension
- Basilar or hemiplegic migraine
- Use of ergots within 24 hours
Status Migrainosus (>72 Hours)
| Treatment | Dose |
|---|---|
| IV fluids | Aggressive rehydration |
| IV antiemetics | Metoclopramide, prochlorperazine |
| IV NSAIDs | Ketorolac |
| IV magnesium | 1-2 g IV |
| IV dexamethasone | 10 mg |
| Valproate IV | 500-1000 mg (if refractory) |
| Dihydroergotamine (DHE) | 1 mg IV (if no contraindications) |
Rescue Therapy
For Refractory Cases:
| Agent | Notes |
|---|---|
| Magnesium sulfate | 1-2 g IV over 15-30 min |
| Valproate sodium | 500-1000 mg IV |
| Dihydroergotamine (DHE) | 0.5-1 mg IV; may repeat |
| Opioids (last resort) | IV morphine or hydromorphone; risk of rebound |
Disposition
Discharge Criteria
- Pain controlled
- Able to tolerate oral intake
- No red flag symptoms
- Neurological exam normal
- Follow-up with PCP or neurology
Admission Criteria
- Status migrainosus not responding to treatment
- Intractable vomiting/dehydration
- Serious secondary cause identified
- Need for IV medications not available outpatient
Referral
| Indication | Referral |
|---|---|
| Frequent migraines (>/month) | Neurology for prophylaxis |
| Medication overuse | Headache specialist |
| Atypical features | Neurology |
Discharge Prescriptions
| Medication | Notes |
|---|---|
| Triptan (e.g., sumatriptan) | For abortive use at home |
| Antiemetic (e.g., ondansetron, metoclopramide) | As needed |
| NSAID | Naproxen, ibuprofen for mild attacks |
| Dexamethasone pack | May reduce recurrence |
Patient Education
Condition Explanation
- "Migraine is a neurological condition that causes severe headaches with other symptoms like nausea and light sensitivity."
- "We can treat this attack and help prevent future ones."
- "Identifying and avoiding triggers can help."
Home Care
- Take medications early in a migraine attack
- Rest in a dark, quiet room
- Stay hydrated
- Avoid known triggers
- Do not overuse analgesics (risk of medication overuse headache)
Warning Signs to Return
- Worst headache of your life
- Sudden onset "thunderclap" headache
- Fever with headache
- Weakness, numbness, or vision changes
- Headache not responding to usual treatment
Special Populations
Pregnancy
- Avoid triptans, NSAIDs (especially 3rd trimester), ergots
- Acetaminophen is safe
- Metoclopramide is generally safe
- Magnesium may be helpful
- Consult OB for refractory cases
Elderly
- Higher concern for secondary causes
- Triptans: Caution with cardiovascular disease
- Consider GCA in new headache >50 years
Medication Overuse Headache
- Ask about frequency of analgesic use
- Triptans, NSAIDs, opioids, and acetaminophen can all cause
- Prophylaxis is key; consider detox
Quality Metrics
Performance Indicators
| Metric | Target | Rationale |
|---|---|---|
| Red flag assessment documented | 100% | Rule out secondary causes |
| Neurological exam documented | 100% | Standard of care |
| IV antiemetic given | >0% | Effective treatment |
| Avoid opioids for migraine | >0% | Stewardship |
| Dexamethasone for recurrence prevention | >0% | Evidence-based |
Documentation Requirements
- Headache features (POUND)
- Red flag assessment
- Neurological exam findings
- Medications given and response
- Discharge instructions and follow-up
Key Clinical Pearls
Diagnostic Pearls
- SNOOP4 for red flags: Rule out secondary causes
- Migraine is a clinical diagnosis: Imaging only for red flags
- Thunderclap = SAH until proven otherwise: CT → LP
- New headache >50 = GCA, malignancy: Check ESR, imaging
- Normal neuro exam expected in migraine
- Medication overuse is common: Ask about analgesic frequency
Treatment Pearls
- Antiemetics have analgesic properties: Metoclopramide, prochlorperazine
- Diphenhydramine prevents akathisia: Give with metoclopramide
- Triptans are first-line abortive: If no contraindications
- Dexamethasone reduces recurrence: 10 mg IV
- Avoid opioids: Not first-line; risk of rebound
- IV fluids help: Dehydration is common
- Magnesium for refractory cases: 1-2 g IV
Disposition Pearls
- Most can be discharged: With abortive prescriptions
- Neurology for frequent migraines: For prophylaxis discussion
- Admit for status migrainosus refractory to ED treatment
- Educate on triggers and early treatment
References
- Headache Classification Committee of the International Headache Society. The International Classification of Headache Disorders, 3rd edition. Cephalalgia. 2018;38(1):1-211.
- Friedman BW, et al. Randomized trial of IV metoclopramide plus diphenhydramine for acute migraine. Neurology. 2017;89(21):2194-2197.
- Orr SL, et al. Canadian Headache Society guideline for migraine in adults. CMAJ. 2021;193(26):E1051-E1066.
- Marmura MJ, et al. The acute treatment of migraine in adults: The American Headache Society evidence assessment of migraine pharmacotherapies. Headache. 2015;55(1):3-20.
- Dodick DW. Migraine. Lancet. 2018;391(10127):1315-1330.
- Colman I, et al. Parenteral dexamethasone for acute severe migraine headache: meta-analysis. BMJ. 2008;336(7657):1359-1361.
- AAN Clinical Practice Guideline. Treatment of migraine in adults. 2019.
- UpToDate. Acute treatment of migraine in adults. 2024.