Mastering Minor Care: Management of Migraines

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Case

A middle aged female with a past medical history of recurrent headaches presents to the Emergency department due to a headache that has been ongoing for the past 8 hours.  She said when she woke up, she felt a little foggy and noticed a small visual aura. These are symptoms she has had before, usually around once a month. She learned about the symptoms from her parents who both also suffer from migraines and have let her use their migraine medication from time to time with good effect. 

background 

Migraines are the fifth leading cause of ED visits in the US and are the seventh leading cause of time spent disabled worldwide.[1,2]. The associated disability is further magnified as their incidence increases among persons 15-40 years of age who are typically less disabled.[2] This increasing incidence is also paired with a 2-3x increase in prevalence in women when compared to men.   

Evaluation , Red flags , and Diagnosis

Migraine-type headaches are categorized as one of the three primary headaches along with cluster and tension headaches.  Generally, migraines are characterized by lasting hours with a unilateral pulsating quality that is further complicated by nausea, vomiting, photophobia, and phonophobia. Often these symptoms will be preceded by promontory symptoms consisting of fatigue, photophobia or auras.  It is also important to remember that migraines can present as a stroke mimic due to auras involving the retina, brainstem, and hemiplegia. Diagnosis in the presence of these neurologic deficits should be done as a diagnosis of exclusion. [3]. The importance of doing and documenting a complete neurologic exam cannot be over emphasized. Any neurologic deficits should immediately raise the suspicion of subarachnoid hemorrhage or stroke.

Table 1. Diagnostic Criteria for Migraines

Table 1. Diagnostic Criteria for Migraines

When the diagnosis of migraine is in doubt the ID- Migraine Tool can be used which has been shown to have 93% Positive Predictive Value for identifying migraine in the primary care setting (sensitivity 0.81, specificity  0.75). [4]

Table 2. ID-Migraine Decision AID

Table 2. ID-Migraine Decision AID

Table 3. Migraine MIMICS

Table 3. Migraine MIMICS

Any presentation for migraine should never be assumed to be “just” a migraine until given its due amount of thought.  Ensuring red flag symptoms such as thunderclap onset, focal neurologic findings, fever, head trauma, or altered mental status are not present can be reassuring that concerning emergent pathology is not present. [5] In addition, it is important to remember that not all patients with subarachnoid hemorrhage have thunderclap headache. It is also important how you ask about the “worst headache of their life.” Many patients may want to justify their trip to the ED. It may be helpful to ask patients “when was the last time you had a headache this severe.” This may save you working up a simple migraine for subarachnoid hemorrhage. If no red flags symptoms are present and the headache is similar to previous headaches, it is reasonable to proceed in treating this as a migraine. [6]

Treatment

Migraine treatments in the ED have been the subject of much research to identify the best treatments for pain relief. ED-based guidelines for the best treatment have been published by the American Headache Society and in Emergency Medicine literature.   

Evidence-Based Opening Salvo

  • Prochlorperazine* 10mg with diphenhydramine as needed for akathisia

    • Metoclopromide 10mg is also an alternative with lower rate of akathisia and favorable treatment in patients who are pregnant

  • Ketorolac 15mg*

  • Dexamethasone 10mg to 25mg (to prevent headache reoccurrence)

*Treatments may be repeated at 1 hour

Other treatments to consider*

  • IV Fluids (1L of lactated ringers) [8]

  • Magnesium 1-2 grams

*Data on the efficacy of magnesium and fluids are limited. Magnesium has had multiple trials with mixed results but ED-based trials have shown some benefit. The evidence for fluids is more limited but does have a very small RCT of 50 patients showing no benefits but was not powered to show a possible small effect size. 

Treatments that are may be considered but currently lack evidence

  • Droperidol

  • Haloperidol

  • Valproate

  • Ketamine (0.1mg/kg IV)

  • Propofol (30mg IV with 10-20mg bolus every 3-5 minutes for up to 120mg)

Treatments to Avoid for ED treatment

  • Triptans and Ergots

    • Sumatriptan

    • Lasmiditan [9]

  • Dihydroergotamine

    • Ergotamine 

Contraindications are important to remember including a history of heart disease, stroke, uncontrolled hypertension, use of Ergots or triptans in the past 24 hours. The risk of adverse events is thought to be less for Lasmiditan.

Opioids and Opiates

  • These have no effect to resolve the underlying cause of migraines and are plagued with migraine recurrence.

Other Treatment agents and adjuncts 

Nerve Blocks

  • Sphenopalatine Nerve Block: Prior case series in 1990s demonstrated improvement of symptoms in 55% of patients that received intranasal lidocaine in sphenopalatine region, however more recent RCTs have been unable to replicate similar results when compared to placebo [11] [12].

    • Two methods to perform sphenopalatine nerve block [13]:

      • Placement of lidocaine/bupivicaine soaked cotton tip applicator in bilateral nares and letting applicator sit for 10 minutes prior to removal

      • Atomization of lidocaine/bupivicaine via MAD atomizer in nares with pressure held for 30 seconds

    • Demonstration of sphenopalatine nerve block can be found here [14].

  • Occipital Nerve Block: Recent meta-analysis/systematic review by Tang et. al exploring 6 RCTs demonstrated reduction in headache severity, amount of headache days, and amount of medication consumed for headache in patients receiving occipital nerve blocks. [15]

    • Walkthrough of performing an occipital nerve block can be found here. [16]

Novel Agents (Likely outside of the scope of acute treatment)

  • Calcitonin-gene related peptide (CGRP)  Antagonist

    • Erenumab-aooe

    • Fremanezumab

    • Galcanezumab-gnlm 

Case follow up 

The patient was treated initially with ketorolac 15mg IV, prochlorperazine 10mg IV, and dexamethasone 10mg IV.  After an hour of treatment, the patient’s pain was moderately improved but began suffering akathisia and was given 25mg of diphenhydramine as well as a repeat dose of prochlorperazine.  Magnesium and IV fluids were given at this time as well. After one more hour, the patient’s migraine had resolved. She was given a referral to a primary care provider and discharged with a prescription for sumatriptan. She was discharged from the Emergency Department.  

AUTHOR: Chris Zalesky, MD, mS

Dr. Zalesky is a PGY-1 in Emergency Medicine at the University of Cincinnati

POST AND PEER EDITING: SHAN MODI, MD

Dr. Modi is a PGY-3 in Emergency Medicine at the University of Cincinnati and Resident Editor of the ‘Minor Care Series’

FACULTY EDITOR: EDMOND HOOKER, MD, DRPH

Dr. Hooker is an Assistant Professor of Emergency Medicine at the University of Cincinnati and Faculty Editor of the ‘Minor Care Series’ 

References 

1. National Hospital Ambulatory Medical Care Survey: 2016 Emergency Department Summary Tables. Available from: https://www.cdc.gov/nchs/data/nhamcs/web_tables/2016_ed_web_tables.pdf

2. Charles A. Migraine. N Engl J Med 2017;377(6):553–61.

3. Headache Classification Committee of the International Headache Society (IHS) The International Classification of Headache Disorders, 3rd edition. Cephalalgia 2018;38(1):1–211.

4. Lipton RB, Dodick D, Sadovsky R, et al. A self-administered screener for migraine in primary care: The ID Migraine validation study. Neurology 2003;61(3):375–82.

5. Friedman BW. Managing Migraine. Ann Emerg Med 2017;69(2):202–7.

6. Friedman BW. Chapter 21 - Presentation of Headache in the Emergency Department and its Triage. In: Diamond S, editor. Headache and Migraine Biology and Management. San Diego: Academic Press; 2015. p. 267–76.

7. Orr SL, Friedman BW, Christie S, et al. Management of Adults With Acute Migraine in the Emergency Department: The American Headache Society Evidence Assessment of Parenteral Pharmacotherapies. Headache 2016;56(6):911–40.

8. Jones CW, Remboski LB, Freeze B, Braz VA, Gaughan JP, McLean SA. Intravenous Fluid for the Treatment of Emergency Department Patients With Migraine Headache: A Randomized Controlled Trial. Ann Emerg Med 2019;73(2):150–6.

9. Kuca B, Silberstein SD, Wietecha L, et al. Lasmiditan is an effective acute treatment for migraine: A phase 3 randomized study. Neurology 2018;91(24):e2222–32.

10. Binfalah M, Alghawi E, Shosha E, Alhilly A, Bakhiet M. Sphenopalatine Ganglion Block for the Treatment of Acute Migraine Headache. Pain Res Treat 2018;2018:2516953.

11. Maizels M, Scott B, Cohen W, Chen W. Intranasal lidocaine for treatment of migraine: a randomized, double-blind, controlled trial. JAMA. 1996;276(4):319-321.

12. Schaffer JT, Hunter BR, Ball KM, Weaver CS. Noninvasive sphenopalatine ganglion block for acute headache in the emergency department: a randomized placebo-controlled trial. Ann Emerg Med. 2015;65(5):503-510. doi:10.1016/j.annemergmed.2014.12.012

13. Alternative Headache Therapies. REBEL EM - Emergency Medicine Blog. June 2017. https://rebelem.com/alternative-headache-therapies/. Accessed February 15, 2020.

14. Shih J, MD, RDMS, Gaafary C, MD. Trick of the Trade: Sphenopalatine Ganglion Block for Treatment of Primary Headaches. ALiEM. March 2017. https://www.aliem.com/trick-sphenopalatine-ganglion-block-primary-headaches/. Accessed February 15, 2020.

15. Mellick LB, McIlrath ST, Mellick GA. Treatment of headaches in the ED with lower cervical intramuscular bupivacaine injections: a 1-year retrospective review of 417 patients. Headache. 2006;46(9):1441-1449. doi:10.1111/j.1526-4610.2006.00586.x

15. Tang Y, Kang J, Zhang Y, Zhang X. Influence of greater occipital nerve block on pain severity in migraine patients: A systematic review and meta-analysis. Am J Emerg Med 2017;35(11):1750–4.

16. Greater Occipital Nerve Block. http://www.usra.ca/pain-medicine/specific-blocks/head-neck/gon.php. Accessed February 15, 2020.