Migraine

Question 1

Symptoms / Diagnostic Criteria

Answer 1

• Headache lasting 4-72 hours

•	2+ of: 
o	unilateral 
o	pulsatile 
o	moderate to severe pain intensity (inhibits daily activity)
o	aggravated by activity

• Associated with 1+ of:
o N/V
o photo + phono-phobia

POUND
Pulsating 
4-72 hOurs
Unilateral
Nausea Disabling

Question 2

Aura Symptoms / Diagnostic Criteria

Answer 2

• Aura (visual distortion, food craving, ↑sensory perception):
o reversible visual (i.e. flickering lights / spots / lines / loss of vision)
o reversible sensory (i.e. pins + needles, numbness)
o reversible speech/language
o NO motor weakness?

• Aura must have 2+ of:
o Aura develops gradually >/ 5 min and / or different aura sx in succession >/5 min
o Aura sx last 5-60 min at least on aura sx is positive,
o Homonymous visual symptoms and / or at least one aura sx unilateral sensory
o Headache occurs within 60 min of aura

Question 3

Headache Red Flags

Answer 3

SNOOPS:
• Systemic: (fever, HTN, myalgias, weight loss)
• Neuro Symptoms: (confusion, AMS, papilledema, Visual Field Defect, FND, seizure)
• Onset: sudden / abrupt / split second
• Older patient: new onset or progressive > 50
• Previous Hx: New / Different H/A, Worsening over time / Change in severity / Worse in the am (↑ICP)
• Secondary Risk Factors: Hx of HIV / CA
o Precipitated by a valsalva

Systemic symptoms 
Neuro symptoms 
Neoplasm
Older than 50 
Onset sudden 
Pattern change 
Positional
Precipitated by valsalve
Palilledema
Pregnancy
Painful eye 
Posttraumatic
Pathology like HIV
Painkiller overuse

Question 4

Management Principles

Answer 4

• Early treatment within 1 hr of H/A
• Subcut or IN if peak to disability is < 1 hr or if pt awakes w/ h/a or ++n/v
• Limit <14 d/mo Tylenol / NSAID / ASA + <9 d / month of triptan to prevent medication overuse

Question 5

Pharmacologic Management for Mild

Answer 5

• Acetaminophen 1,000 mg
• Ibuprofen 400 mg
• Naproxen 500 mg
• Diclofenac 50 mg
• Ketorlac 10 – 30 mg IV or IM
• Metoclopramide 10 mg IV

Question 6

Pharmacologic Management for Moderate - Severe

Answer 6

•	Rizatriptan 10 mg PO
•	Almotriptan 12.5 mg PO
•	Zolmitriptan 2.5-5mg
•	Sumatriptan 100 mg PO
***If does fails, take another drug class instead of 2nd dose***
***Expect relief in 2 hours***

Question 7

C/i for Triptans

Answer 7

CVD (CVA, TIA, MI, PVD, coronary spasm, prinzmetal angina), WPW, pregnancy, basilar migraines, ergotamine use within the last 24 hrs

Question 8

Medication for refractory Migraine

Answer 8

• Ergotamine / dihydroergotamine
• Domperidone / Metoclopramide
• Prochlorperazine
• Oral Dex

Sphenopalatine ganglion block
Calcitonin gene-related peptide receptor antagoist (rimegepant)

Question 9

Meds for Pediatric Migraine

Answer 9

• Ibuprofen 10 mg/kg

* +/- triptan (IF > 12 yo, IN sumatriptan 10 mg if 20-39 kg, 20 mg if > 40 mg)

Question 10

ER treatment for Migraine

Answer 10

• 1 L bolus NS
• 10 mg prochloperazine w/ 25 mg diphenhydramine
• 30 mg ketorolac
• 10 mg dexamethasone

Question 11

Prophylaxis treatment for 1st line and 2nd line (CFP)

Answer 11

First Line CFP:
•	Metoprolol / Propanolol
•	Amitriptyline 
Second Line CFP:
•	Topiramate
Valproic acid
Calcitrion Gene Related Peptide Antagonist
•	Gabapentin
•	Candesartan

Question 12

Prevention strategies

Answer 12

• Headache Diary
• Identify food / alcohol trigger
• Stress reduction, regular eating, regular sleep, aerobic exercise
• Avoid analgesic drugs > 9d/month
• Avoid Triggers: Environmental, Lifestyle, Hormonal, Emotional, Medications, Dietary

CBT
Biofeedback
Decrease caffeine

Question 13

DDX for treatment failure

Answer 13

• Acute Medication / analgesia overused
• Medication dose too little or used too late
• Inadequate medication for degree of disability, inappropriate route
• Failure to use adjunct (caffeine, antiemetic)
• Inaccurate diagnosis