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Emergency And Acute Medicine – Migraine Headache
Overview And Pathophysiology
Migraine is a chronic, episodic primary headache disorder and accounts for the majority of headache-related emergency department visits, with approximately one million visits annually. It is three times more common in women, and prevalence peaks in the fourth decade of life. Migraine is no longer considered a primarily vascular disorder. Instead, it reflects a neurovascular process characterized by abnormal trigeminal nerve activation, stimulation of nociceptive pathways within the brainstem, disordered sensory processing, and autonomic dysfunction. Vascular dilation is reactive rather than causative. Cortical spreading depression is believed to underlie migraine aura.
Diagnostic Criteria And Subtypes
Migraine without aura is defined by established clinical criteria requiring at least five attacks lasting 4–72 hours, with headaches demonstrating at least two of the following features: unilateral location, pulsating quality, moderate to severe intensity that interferes with daily activity, and worsening with or avoidance of routine physical activity. During attacks, patients experience nausea and/or vomiting and photophobia with phonophobia, and symptoms are not attributable to another disorder.
Migraine with aura is less common and consists of reversible neurologic symptoms that typically precede headache but may occur simultaneously or afterward. Aura most often involves visual or sensory disturbances. Less common subtypes include basilar-type migraine, which may present with dysarthria, vertigo, ataxia, diplopia, or decreased level of consciousness; hemiplegic migraine, characterized by fully reversible motor weakness; and retinal migraine, involving recurrent monocular visual disturbances.
Special Population Considerations
In children, migraines more often present with bilateral pain and shorter duration. Associated symptoms may be difficult to verbalize and are often inferred from behavior. Cyclical vomiting syndrome is associated with pediatric migraine, and placebo response rates are high. Migraine has a strong genetic basis with variable penetrance and is influenced by environmental factors.
Clinical Presentation
History often reveals triggers such as chocolate, cheese, nuts, alcohol, sulfites, monosodium glutamate, stress, or menstruation. A prodrome may precede the headache by several days and can include yawning, drowsiness, or cognitive and emotional changes. Aura typically precedes headache by up to one hour and most commonly consists of visual phenomena such as scintillating scotoma or fortification spectra, as well as sensory symptoms like numbness or tingling.
The headache itself is usually unilateral and throbbing, although it may be bilateral, and is sufficiently severe to impair function. Symptoms typically develop gradually and are accompanied by nausea, vomiting, photophobia, phonophobia, and sometimes osmophobia. Patients frequently report similar headaches in the past.
Physical Examination Findings
Physical examination is generally normal. Allodynia, or pain from normally nonpainful stimuli, may be present and suggests a more refractory migraine. Funduscopic examination and assessment of visual fields should be performed. Elevated blood pressure or sinus tenderness does not exclude migraine as the diagnosis.
Initial Evaluation Strategy
Migraine is a clinical diagnosis based on history and examination. Patients presenting with a new headache syndrome or atypical features may require further evaluation, including neuroimaging or cerebrospinal fluid analysis, to exclude secondary causes.
Diagnostic Testing Considerations
No routine laboratory studies, imaging, or procedures are required for patients with a typical migraine presentation. Testing is reserved for cases with red flags or diagnostic uncertainty.
Differential Diagnosis
Conditions to consider include cluster headache, medication overuse headache, tension-type headache, allergic or viral rhinosinusitis, idiopathic intracranial hypertension, and reversible cerebral vasoconstriction syndrome.
Prehospital And Early Emergency Care
Patients benefit from a calm, dark environment. Supplemental oxygen may provide symptomatic relief. Early goals include exclusion of secondary headache causes and rapid, effective analgesia.
Emergency Department Management
A detailed history usually excludes secondary pathology. Treatment should prioritize nonopioid analgesia. Intravenous saline hydration is often beneficial. Clear communication of the diagnosis and education regarding trigger avoidance are important aspects of care. In pregnancy, metoclopramide and prochlorperazine are preferred treatment options.
Pharmacologic Therapy
First-line abortive therapy in the emergency department includes dopamine antagonists such as prochlorperazine or droperidol administered with diphenhydramine to prevent akathisia, as well as metoclopramide or trimethobenzamide. Triptans, such as subcutaneous sumatriptan, are effective but should be avoided in patients with significant cardiac risk factors. Ergot derivatives, including dihydroergotamine, may be used with antiemetics in appropriate patients. Nonsteroidal anti-inflammatory drugs such as ketorolac are commonly effective. Corticosteroids, including dexamethasone, may be used to reduce post-discharge headache recurrence. Opioids should be reserved only for refractory cases when other therapies have failed.
Disposition And Follow-Up Planning
Admission is indicated for patients with persistent severe headache, focal neurologic deficits, intractable vomiting, electrolyte abnormalities, inability to tolerate oral intake, or coexisting medication overuse headache. Patients may be discharged once pain relief is achieved and secondary causes have been excluded. Individuals with chronic or frequent episodic migraine should be referred for specialist care.
Outpatient Care And Prevention
Patients should be encouraged to maintain a headache diary to identify triggers and patterns. Ongoing primary care or specialty follow-up is essential to establish effective outpatient abortive and preventive therapies.
Clinical Pearls And Common Pitfalls
Opioids should not be used as first-line therapy for migraine in the emergency department. Migraine commonly recurs after ED discharge, so patients should leave with an appropriate prescription and management plan. It is critical to distinguish migraine, a chronic recurrent disorder, from new-onset or progressively worsening headaches that may signal serious underlying disease.
Overview And Pathophysiology
Migraine is a chronic, episodic primary headache disorder and accounts for the majority of headache-related emergency department visits, with approximately one million visits annually. It is three times more common in women, and prevalence peaks in the fourth decade of life. Migraine is no longer considered a primarily vascular disorder. Instead, it reflects a neurovascular process characterized by abnormal trigeminal nerve activation, stimulation of nociceptive pathways within the brainstem, disordered sensory processing, and autonomic dysfunction. Vascular dilation is reactive rather than causative. Cortical spreading depression is believed to underlie migraine aura.
Diagnostic Criteria And Subtypes
Migraine without aura is defined by established clinical criteria requiring at least five attacks lasting 4–72 hours, with headaches demonstrating at least two of the following features: unilateral location, pulsating quality, moderate to severe intensity that interferes with daily activity, and worsening with or avoidance of routine physical activity. During attacks, patients experience nausea and/or vomiting and photophobia with phonophobia, and symptoms are not attributable to another disorder.
Migraine with aura is less common and consists of reversible neurologic symptoms that typically precede headache but may occur simultaneously or afterward. Aura most often involves visual or sensory disturbances. Less common subtypes include basilar-type migraine, which may present with dysarthria, vertigo, ataxia, diplopia, or decreased level of consciousness; hemiplegic migraine, characterized by fully reversible motor weakness; and retinal migraine, involving recurrent monocular visual disturbances.
Special Population Considerations
In children, migraines more often present with bilateral pain and shorter duration. Associated symptoms may be difficult to verbalize and are often inferred from behavior. Cyclical vomiting syndrome is associated with pediatric migraine, and placebo response rates are high. Migraine has a strong genetic basis with variable penetrance and is influenced by environmental factors.
Clinical Presentation
History often reveals triggers such as chocolate, cheese, nuts, alcohol, sulfites, monosodium glutamate, stress, or menstruation. A prodrome may precede the headache by several days and can include yawning, drowsiness, or cognitive and emotional changes. Aura typically precedes headache by up to one hour and most commonly consists of visual phenomena such as scintillating scotoma or fortification spectra, as well as sensory symptoms like numbness or tingling.
The headache itself is usually unilateral and throbbing, although it may be bilateral, and is sufficiently severe to impair function. Symptoms typically develop gradually and are accompanied by nausea, vomiting, photophobia, phonophobia, and sometimes osmophobia. Patients frequently report similar headaches in the past.
Physical Examination Findings
Physical examination is generally normal. Allodynia, or pain from normally nonpainful stimuli, may be present and suggests a more refractory migraine. Funduscopic examination and assessment of visual fields should be performed. Elevated blood pressure or sinus tenderness does not exclude migraine as the diagnosis.
Initial Evaluation Strategy
Migraine is a clinical diagnosis based on history and examination. Patients presenting with a new headache syndrome or atypical features may require further evaluation, including neuroimaging or cerebrospinal fluid analysis, to exclude secondary causes.
Diagnostic Testing Considerations
No routine laboratory studies, imaging, or procedures are required for patients with a typical migraine presentation. Testing is reserved for cases with red flags or diagnostic uncertainty.
Differential Diagnosis
Conditions to consider include cluster headache, medication overuse headache, tension-type headache, allergic or viral rhinosinusitis, idiopathic intracranial hypertension, and reversible cerebral vasoconstriction syndrome.
Prehospital And Early Emergency Care
Patients benefit from a calm, dark environment. Supplemental oxygen may provide symptomatic relief. Early goals include exclusion of secondary headache causes and rapid, effective analgesia.
Emergency Department Management
A detailed history usually excludes secondary pathology. Treatment should prioritize nonopioid analgesia. Intravenous saline hydration is often beneficial. Clear communication of the diagnosis and education regarding trigger avoidance are important aspects of care. In pregnancy, metoclopramide and prochlorperazine are preferred treatment options.
Pharmacologic Therapy
First-line abortive therapy in the emergency department includes dopamine antagonists such as prochlorperazine or droperidol administered with diphenhydramine to prevent akathisia, as well as metoclopramide or trimethobenzamide. Triptans, such as subcutaneous sumatriptan, are effective but should be avoided in patients with significant cardiac risk factors. Ergot derivatives, including dihydroergotamine, may be used with antiemetics in appropriate patients. Nonsteroidal anti-inflammatory drugs such as ketorolac are commonly effective. Corticosteroids, including dexamethasone, may be used to reduce post-discharge headache recurrence. Opioids should be reserved only for refractory cases when other therapies have failed.
Disposition And Follow-Up Planning
Admission is indicated for patients with persistent severe headache, focal neurologic deficits, intractable vomiting, electrolyte abnormalities, inability to tolerate oral intake, or coexisting medication overuse headache. Patients may be discharged once pain relief is achieved and secondary causes have been excluded. Individuals with chronic or frequent episodic migraine should be referred for specialist care.
Outpatient Care And Prevention
Patients should be encouraged to maintain a headache diary to identify triggers and patterns. Ongoing primary care or specialty follow-up is essential to establish effective outpatient abortive and preventive therapies.
Clinical Pearls And Common Pitfalls
Opioids should not be used as first-line therapy for migraine in the emergency department. Migraine commonly recurs after ED discharge, so patients should leave with an appropriate prescription and management plan. It is critical to distinguish migraine, a chronic recurrent disorder, from new-onset or progressively worsening headaches that may signal serious underlying disease.
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