Migraine

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