Migraine Headache
Migraine Headache
Anticipated LOS <18 hours
Classic symptoms of migraine headache
Normal Imaging of brain if completed (no history of migraines, change in characterization of migraine, anticoagulation, etc.)
No focal neurologic signs
Ensure no infectious etiology for headache
Normal fundoscopic exam
No red flags: no “worst headache of life”, no fevers, no postural worsening of headache
Negative pregnancy test
Focal Neurologic signs
Abnormal CT of brain
Abnormal LP if performed, opening pressure measured
Blocked VP shunt
Frequent ED visits- suspected habitual patient/narcotic abuse (also excluded from admission)
Hypertensive emergency (SBP > 200 or DBP >110)
Suspected meningitis
Subarachnoid hemorrhage
Altered mental status
Immunocompromised patient (transplant, poorly controlled HIV, on chronic steroids)
IV fluids (0.9 normal saline x 1 liter bolus then at 150cc/hr)
Medications:
No narcotics
Step 1. Prochlorperazine 10 mg IV or Droperidol 2.5 mg IV or Metoclopramide 10 mg IV
Step 2. Ketorocal 15 mg IV, Acetaminophen 1000 mg IV
Step 3. Check QTc If < 480, Repeat Step 1
Step 4. Magnesium sulfate 1gm IV over 30 minutes and dexamethasone 10 mg IV or PO.
Step 5. Sphenopalatine Ganglion Block Bilaterally (anyone can do this!) and/or Occipital Nerve block
Step 6. Valproate 500mg IV over 1 hour, if persistent headache repeat dose in 30 minutes.
Step 7. Nonrebreather for 30 minutes.
Step 8. If Zeccola is available, ultrasound guided pterygopalatine fossa / trigeminal root block
Step 9. Ketamine 0.5 mg / kg IV bolus (max dose 35 mg).
Step 10. Discuss with neurology, likely needs admission for Dihydroergotamine
Radiologic studies:
Consider MRI if patient has ataxia, vertigo, nystagmus
Consider CT head without contrast with persistent headache.
Consult Neurology if persistent headache or if without resolution or if DHE to be used.
Disposition
Improvement of Headache
Persistent Debilitating headache
Deterioration in clinical course
Learning Links:
emDOCS Migraine Article: https://www.emdocs.net/pain-profiles-ed-migraine-management-the-new-kid-on-the-block/