Migraine Headache



Diagnostic Criteria for Migraine

Migraine without aura
  • Headaches last 4-72 hours
  • Two of the following:
    • Unilateral
    • Throbbing
    • Moderate to severe intensity
    • Worsened by usual physical activity
     
  • At least one of the following
    • Photophobia
    • Phonophobia
    • Nausea/vomiting
     
  • No evidence of other underlying disease

Migraine with aura

  • Transient neurologic symptoms
    • Start gradually over 5-20 min
    • Last less than 60 min
    • Headache as above starts within 60 min
     
  • Types of aura
    • Visual – flickering lights, spots or lines
    • Sensory – pins and needles, numbness
    • Dysphasic speech
    Fully reversible symptoms
     
  • At least two attacks of headache with aura

Diagnosis of Migraine Headache

  • Clinical diagnosis – primarily history
  • Negative neurological examination
  • Neuroimaging unnecessary, except with
    – Unexplained abnormal neuro findings
    – Headaches that do not fit the strict definition
     
  • Headache “red flags”
    – Rapidly increasing headache frequency
    – History of lack of coordination
    – History of localized neurological signs
    – Headaches that awaken from sleep

 

  • Other Tests/Criteria (International Headache Society classification)
    • IHS Aura Diagnostic Criteria (require aura to have ≥ 2 of following fully reversible Sx)
      • Dysarthria
      • Vertigo
      • Tinnitus
      • Hypacusia
      • Diplopia
      • Visual Sx simultaneously in both temporal and nasal fields of both eyes
      • Ataxia
      • Decreased level of consciousness
    • IHS Migraine with Aura Subforms Criteria (recognize 6 subforms of aura w/ migraine headache)
      • Typical aura w/ migraine headache
      • Typical aura w/ non-migraine headache
      • Typical aura w/o headache
      • Familial hemiplegic migraine (FHM)
      • Sporadic hemiplegic migraine
      • Basilar type migraine
         
    • Typical aura
      • ≥ 1 of following without motor weakness
        • Fully reversible visual Sx, including positive features (flickering lights, spots, or lines) and/or negative features (loss of vision)
        • Fully reversible sensory Sx, including positive features (pins and needles) and/or negative features (numbness)
        • Fully reversible dysphasic speech disturbance
      • ≥ 2 of following characteristics
        • Homonymous visual Sx and/or unilateral sensory Sx
        • ≥ 1 aura Sx develops gradually over ≥ 5 minutes and/or different aura Sx occur in succession over ≥ 5 minutes
        • Each Sx lasts 5-60 mins
           
    • Hemiplegic migraine aura
      • Familial hemiplegic migraine
        • Aura consists of fully reversible motor weakness and at least one 1st or 2nd-degree relative has had attacks
      • Sporadic hemiplegic migraine
        • Diagnosed when no 1st or 2nd degree relative has had attacks
           
    • Basilar type aura
      • Migraine with aura Sx originating from brainstem and/or from both hemispheres simultaneously
      • No motor weakness
         
    • Migraine without aura
      • At least 5 attacks lasting 4-72 hrs if untreated
      • 2-48 hrs if < 15 yo
      • Headache with at least 2 of following
        • Unilateral location
        • Pulsating quality
        • Moderate or severe intensity (inhibits daily activities)
        • Aggravated by activity
      • At least one of following
        • Nausea &/or vomiting
        • Photophobia and phonophobia
           
    • Migraine with aura
      • ≥ 2 attacks including 3 of following
        • ≥ 1 fully reversible aura Sx indicating focal cerebral, cortical, and/or brainstem dysfunction
        • ≥ 1 aura Sx developing gradually over > 4 min, or ≥ 2 Sx in succession
        • No aura Sx lasting > 60 min
          • Accepted duration is proportionally increased if > 1 aura Sx present
        • headache following aura w/ a free interval of < 60 min
          • headache may also begin before or simultaneously w/ aura
      • Must consider and work up secondary causes of headache when indicated
      • H&P, and neurologic exams do not suggest another disorder

 

Hx/Exam

  • History/Symptoms
    • Assess headache characteristics (onset, location, character, frequency, aggravating/alleviating factors)
    • Prodrome (60%)
      • Onset: hrs to days prior
      • Nonspecific feeling of a migraine coming on may last hrs to days
      • Nausea, food craving, heightened sensory perception, alteration in mood/behavior
      • Depression, yawning, irritable
    • Aura: precede or occur with headache
      • Lasts < 60 mins; visual, sensory, motor
      • Most common: slowly spreading wavy lines, light flashes, blurred vision, scintillating scotomas
      • Paresthesias: slowly spreading hand numbness to arm, face
      • Limb heaviness (w/o weakness), aphasia, hallucinations
    • Common migraine headache symptoms
      • Unilateral throbbing/pulsing pain
        • Frontotemporal/ocular progressing post.
        • Gradually builds over 1-2 hrs; becomes diffuse
      • N/V, anorexia, photophobia, phonophobia
      • May present w/ other Sx
        • Ophthalmoplegic: EOM palsies, optic nerve isch, transient blindness
        • Complicated: permanent neuro deficits, paralysis
        • Vertebrobasilar: vertigo, dizzy, dysarthria, tingling, incoordination
      • Sx usually resolve w/ rest; 4-72 hrs
    • Migraine with aura (classic migraine)
      • Visual auras
        • Sensitivity to light, flickering lights, spots or lines, blurred vision
        • May have temporary vision loss
      • Nonvisual auras
        • Sensory: pins, needles, numbness
        • Speech: dysphasic speech
      • Pain typically unilateral, throbbing
    • Migraine without aura (common migraine)
      • No preceding neurological Sx
      • Pain same as classic migraine
    • Migraine variants
      • Hemiplegic: unilateral motor or sensory aura (may last longer than headache)
      • Ocular or retinal: monocular scotomata or blindness < 1 hr before onset of headache
      • Basilar: disturbance in brainstem function; aura of vertigo, tinnitus, ataxia, dysarthria or diplopia; weakness not present
      • Aura without headache (acephalic): migraine equivalent, usually > 40 yo; scotoma, other neuro Sx absent
      • Migrainous vertigo: vertigo is prevailing or sole symptom
         
  • Physical Exam/Signs
    • Complete exam to r/o other causes
    • Check BP, temp, RR (r/o HTN)
    • Palpate sinuses, temporal art, trigeminal nerve, teeth
    • Complete ophthalmologic exam: papilledema, glaucoma, pupil changes
    • Evaluate for meningeal signs, toxic exposures
    • Complete neuro exam including gait, MS, cerebellar evaluation
 

Labs/Imaging

  • Labs/Tests
    • CBC: r/o anemia, infxn
    • ABG: r/o hypoxia, toxin
    • ESR: r/o temporal arteritis
    • Beta-hCG: if ind
    • LP/CSF: r/o SAH (xanthochromia by spectrophotometry), meningitis
      • Obtain CT prior to r/o incr ICP, mass
      • Measure pressures
         
  • Imaging
    • Radiologic indications (consider imaging if abnormal neurological findings or atypical features)
      • If first time, "worst headache of life", change in Sx, focal neuro deficit
      • Head CT: r/o CVA, SAH, mass
         
 

Treatment of Migraine

ED Treatment

Drug Dosing and Adjuncts Contraindications (CI), Precautions (PC), and Notes
Dihydroergotamine 1 mg IV over 3 min; pretreat with metoclopramide or chlorpromazine or prochlorperazine to reduce nausea and vomiting CI: Pregnancy, hypertension (uncontrolled), coronary artery disease, recent sumatriptan use, hemiplegic or basilar migraine
PC: May cause nausea, vomiting, diarrhea, abdominal pain
Sumatriptan 6 mg SC CI: Pregnancy, hypertension (uncontrolled), coronary artery disease, ergot use in past 24 h, monoamine oxidase inhibitor use, hemiplegic or basilar migraine
PC: Minor adverse effects; rarely, coronary artery spasm, myocardial infarction, dysrhythmias
Demerol 25-50 mg IM, IV  
Ketorolac 30 mg IV or 60 mg IM CI: History of peptic ulcer disease (especially in the elderly)
PC: Pregnancy class B drug, avoid in third trimester
Nausea/Vomiting
Promethazine 12.5-25 mg PO/IM q4-6h  
Zofran ODT 4-8 mg SL/IV/IM  
Chlorpromazine Pretreat with normal saline bolus to minimize hypotension; 7.5 mg IV PC: Pregnancy class C drug, may cause hypotension, drowsiness, dystonic reactions
Note: effective antiemetic
Prochlorperazine 5–10 mg IV or PR PC: Pregnancy class C drug, may cause drowsiness, dystonic reactions
Note: effective antiemetic
Metoclopramide 10 mg IV PC: Pregnancy class B drug, may cause drowsiness, dystonic reactions
Note: effective antiemetic
Droperidol 2.5 mg IV slow, or 2.5 mg IM for N/V PC: Cases of QT-interval prolongation and/or torsades de pointes have been reported
Olanzapine 10 mg IM QT-interval prolongation
Magnesium sulfate 2 grams IV over 30 min Note: nonvalidated but occasionally useful therapy (effective in eclampsia)
Methylprednisolone 125 mg IV or IM Note: nonvalidated but occasionally useful rescue therapy 
Dexamethasone 10 mg IV Note: Decreased headache reoccurrence when used as adjunctive therapy 
 

Prevention

Indications
  • Headaches significantly interfere with usual activities
  • Overuse of acute therapies
  • Adverse events with acute therapies
  • Patient preference
  • Certain migraine variants:
    • Hemiplegic migraines
    • Basilar migraines
    • Prolonged aura
Preventive
Symptoms linked to menstrual cycle   - Control Cycle
- magnesium oxide : 400-800 mg orally once daily
Without predominant depression, aura, hemiplegic/basilar features   Primary Options
valproate sodium : 250-500 mg orally (delayed-release) twice daily; 500-1000 mg orally (extended-release) once daily
topiramate : 25-200 mg/day orally given in 2 divided doses

Secondary Options
gabapentin : 300 mg orally once daily on first day, followed by 300 mg twice daily on second day, followed by 300 mg three times daily on third day, then increase gradually according to response, maximum 3600 mg/day
adjunct TCA:

Primary Options
amitriptyline : 10-150 mg/day orally

Secondary Options
doxepin : 10-150 mg/day orally
nortriptyline : 10-125 mg/day orally
 
adjunct Beta-Blocker

Primary Options
propranolol hydrochloride : 80-240 mg/day orally (immediate-release) given in 2-4 divided doses
timolol : 10-30 mg/day orally given in 2 divided doses

Secondary Options
atenolol : 50-150 mg/day orally
metoprolol tartrate : 50-250 mg/day orally (immediate-release) given in 2 divided doses
nadolol : 40-240 mg/day orally
 

With frequent or troublesome auras   Lamictal:
adjunct calcium-channel blockers
No calcium-channel blocker is FDA approved for migraine prevention.

Primary Options
verapamil : 80 mg orally (immediate-release) three times daily

Secondary Options
nimodipine : 60 mg orally four times daily
 
with coexisting depression   venlafaxine : 37.5 to 75 mg orally once daily initially, increase according to response, maximum 150 mg/day
duloxetine : 30-60 mg orally once daily
milnacipran : 12.5 to 50 mg orally twice daily
 
with hemiplegic and basilar-type migraine   calcium-channel blockers
No calcium-channel blocker is FDA approved for migraine prevention.

Primary Options
verapamil : 80 mg orally (immediate-release) three times daily

Secondary Options
nimodipine : 60 mg orally four times daily
≥15 headaches per month not responsive to ≥3 pharmacologic therapies   onabotulinumtoxinA
OnabotulinumtoxinA has been found to reduce migraine attacks when injected into glabellar, frontalis, and temporalis muscles compared with placebo.

Treatment of chronic migraine with onabotulinumtoxinA has been shown to reduce headache impact and improve quality of life. [159]

Primary Options
onabotulinumtoxinA : consult specialist for guidance on dose
 

Disposition

Disposition of Patients with Primary Headache Syndromes

  • Regardless of the type of primary headache, poor response to treatment should heighten suspicion of a secondary headache cause and prompt emergent investigations. However, improvement of a presumed primary headache as a result of treatment does not exclude secondary causes. Patients who respond well to ED management usually can be discharged with appropriate follow-up. Occasionally, a patient with intractable migraine may require admission for more aggressive pain control.
     
  • Admit
    • Pts w/ status migrainosus (> 24 hr, dehydration)
    • Pain unresponsive to Tx
    • Tx failures
    • Unclear Dx
  • Discharge
    • Ensure adequate follow-up with PCP, pain meds PRN