Migraine

From IDWiki

Criteria

  • Any two of:
    • unilateral
    • throbbing
    • worse with activity
    • moderate or severe
  • Plus any one of:
    • nausea or vomiting
    • photophobia/phonophobia

Management

Acute/Abortive

  • Goal is to be headache-free within 1 or 2 hours
  • Maximum 2-3 days weekly of medication to prevent rebound headache
  • Abortive therapy within an hour: any triptan
  • Abortive therapy during pain: NSAIDs, acetaminophen, metoclopramide
  • Mild-moderate
    • Diclofenac, naproxen
  • Mod-severe
    • NSAID + triptan

ER protocol

  • A combination of the following, base on severity:
    • Normal saline 1L IV bolus
    • Prochlorperazine 10mg IV
    • Metoclopramide
    • Diphenhydramine 25mg IV
    • Ketorolac 30mg IV
    • Dexamethasone 10mg IV

Preventative

  • Headache diary to identify triggers like stress, hormones, not eating, weather, etc.
  • Start if ≥4 severe headaches per month, for nocturnal/morning headaches, or when interfering with activities
  • Beta-blockers like propanolol, metoprolol, atenololtimolol,
  • TCAs like amitriptyline, venlafaxine
  • Anti-epileptics like valproate
  • Candesartan, lisinopril
  • Butterbur (liver toxicity), riboflavin, magnesium citrate, coenzyme Q, feverfew