PRIMARY HEADACHE

Question 1

MANAGEMENT: MIGRAINE

Answer 1

SEVERE / ED
1 L bolus NS
10 mg Metaclopramide IV w/ 25 mg diphenhydramine
10 mg ketorolac IV or IM
10 mg dexamethasone IV

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

• Limit <14 d/mo Tylenol / NSAID / ASA

MODERATE TO SEVERE MIGRAINE
* Rizatriptan 10 mg PO
* Almotriptan 12.5 mg PO
* Zolmitriptan 2.5-5mg
* Sumatriptan 100 mg PO

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

INDICATIONS FOR CT
Unusual, prolonged, or persistent aura
Increasing frequency, severity, or change in clinical features
First or worst migraine
Basilar
Confusion
Hemiplegia
Later-life migraine
Aura without headache
Headaches always on the same side
Post traumatic

Question 2

DOCUMENTATION: MIGRAINE

Answer 2

DIAGNOSTIC CRITERIA
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

AURA DIAGNOSTIC CRITERIA
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?

Question 3

MANAGEMENT: TENSION

Answer 3

SEVERE / ED
1 L bolus NS
10 mg Metaclopramide IV w/ 25 mg diphenhydramine
10 mg ketorolac IV or IM
10 mg dexamethasone IV

MILD TENSION HEADACHE
Use analgesia <9-15 d / month to prevent medication overuse h/a
* Acetaminophen 1,000 mg
* Ibuprofen 400 mg
* Naproxen 500 mg

Question 4

DOCUMENTATION: TENSION

Answer 4

Headache <15d/month
Lasts 30 min – 7 d

> / 2:
o Pressing / tightening (non-pulsatile)
o Mild-moderate intensity (inhibits 0 prohibits)
o Bilateral
o Not aggravated by routine physical activity

Both of the following:
o 0 N/V
o < photophobia / phonophobia

Question 5

DDX: TREATMENT FAILURE

Answer 5

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

Question 6

MANAGEMENT: CLUSTER

Answer 6

ED MANAGEMENT
100% Inhaled 02 at 6-12 L / min via non-rebreather mask at the beginning of the attack
Sumatriptan 6 mg SC
Prednisone 10 mg PO daily to prevent further attacks

Zolmitriptan 10 mg IN (alternate)

FIRST LINE BRIDGING THERAPY
Unilateral greater occipital nerve block 80 mg methyprednisone with 2 mL of 2% lidocaine

Question 7

DOCUMENTATION: CLUSTER

Answer 7

At least 5 headaches with the following characteristics:

• Severe unilateral orbital, supraorbital +/- temporal pain lasting 15-180 min untreated
• Attack is a/w 1>/ of the following autonomic symptoms (usually unilateral and ipsilateral):

o Conjunctival injection
o Lacrimation
o Nasal congestion
o Rhinorrhea
o Forehead / facial swelling
o Miosis
o Ptosis
o Eyelid Edema
o Agitation, unable to lie down

• Frequency from 8/d to q2d