AHS - Flowchart

NO

YES

NO

YES

Consider neurology consult

Treatment consistently and satisfactorily improves attack severity?

Headache: suspect migraine

Preventive Treatment Plan

Acute Treatment Plan

Consider reasons for failure of nonspecific medication, adjust therapy, reasses after 3 to 4 migraine episodes

Consider reasons for treatment failure and consider alternative therapy if ineffective

Start a migraine specific treatment

Neurology eConsult or consult

Initiate common analgesics

Reassess in 6-12 Months

Mild headache

Moderate-severe headache

Initiate prevention

Continue preventive treatment for 1 to 2 years, consider tapering

Continue preventive treatment for 1 to 2 years, consider tapering

Consider reasons for failur of prevention, adjust therapy, reassess in 3-6 months

Referral to Migraine management Pregnancy and breastfeeding

Initiate acute therapy with or without preventive treatment

Preventive Treatment Plan

Classify by severity of attack

Education on management principles

Diagnose Migraine

Atypical signs or symptoms?

ED Management

Urgent evaluation needed?

Outpatient workup

Perform History and Physical Examination

Is the patient pregnant or breastfeeding?

Goals of prevention met?

Goals of prevention met?

YES

Select a Path

NO

NO

YES

NO

NO

YES

YES

The following 3 questions (ID migraine) with the mnemonic P-I-N, can be used to screen a patient for migraine in a primary care setting:

1. Does light bother you when you have a headache? (Photophobia)
2. Have headaches limited your activities for a day or more in the last 3 months? (Impairment)
3. Are you nauseated or sick to your stomach when you have a headache? (Nausea)

If 2 or 3 answers are affirmative, there is a 93% chance the patient has migraine.Note that ID migraine does NOT exclude secondary headache.

Headache: suspect migraine

Patient education includes:

• Setting realistic expectations, including:
• Expected benefits of treatment
• How long it will take to reach treatment goals
• Selecting a particular treatment, based on factors such as:
• Frequency and severity of headaches
• Degree of headache-related disability
• Associated symptoms including nausea and vomiting
• Response to (and tolerance of) specific medications
• Comorbidities
• Coexisting conditions such as heart disease, pregnancy, and uncontrolled hypertension may limit treatment choices
• Following the treatment regimen
• Understanding adverse effects
• Tracking progress (e.g., diary cards, flow charts, headache calendars to mark days of disability or missed work, school, and family activities)
• Avoiding migraine triggers

Migraine triggers -

• Environmental triggers
• Temperature (exposure to heat or cold), Bright lights or glare, Noise, Head or neck injury, weather changes, motion, Odors (e.g., smoke, perfume), Flying or high altitude, Physical strain
• Lifestyle triggers
• Acute or chronic stress, or relaxation after stress, Skipping meals, Unhealthy diet, Disturbed sleep patterns, Smoking

• Hormonal triggers
• Menarche, Puberty, Ovulation, Menstruation, Using oral contraceptives or estrogen theropy, Pregnancy, Birth of a Child, Menopause
• Emotional triggers
• Anger, Excitement or exhilaration, Let-down response following period of stress
• Pharmacological triggers
• Nitroglycerin, Oral Contraceptives, Hormone therapy, Medications for erectile dysfunction
• Dietary triggers (which vary considerably from patient to patient)
• Citrus fruit, Aspartame, Caffeine, Aged cheese, chocolate, Alcohol (red wine, beer), Foods containing nitrites, Foods containing monosodium glutamate (MSG)
• However, food may not consistently precipitate a migraine – even if a given product has been a trigger in the past

Patient education

Atypical signs or symptoms warranting imaging or additional tests include:

• Fever
• New neurological deficit
• Thunderclap headache (sudden onset of severe headache, maximum intensity immediately or within <60 seconds)
• Headache during sexual activity

• A new, first, or worst headache
• Significant change in headache characteristics
• Increasing frequency of headache attacks or loss of pain free periods
• Headache not responding to treatment
• Existing conditions that predispose to secondary headaches (e.g., pregnancy, cancer, immunosuppression, anticoagulants)
• Signs and symptoms of systemic illness (e.g., weight loss, fever, jaw claudication, hypertension)
• New or unexplained abnormalities on neurologic examination, such as papilledema (see Headache with papilledema)
• Headache that is worse while standing and better while supine (see Orthostatic headache)
• Headache triggered by coughing, sneezing, Valsalva, or similar straining maneuver (see Cough headache)
• Headache precipitated by exercise (see Exercise headache)
• Headache developing only during sleep, causing wakening (see Hypnic headache)
• “Side-locked” headache (exclusively on one side of the head)

• New-onset headache after age 50 (consider giant cell arteritis)

Neuroimaging is not usually warranted for a patient with a history of migraine with stable headaches who has a normal neurologic exam. However, imaging may be warranted in a patient with atypical signs and symptoms or in a patient who does not fall within the strict definition of migraine (or has some additional risk factor) and does not otherwise require urgent evaluation. Migraine commonly presents with mid-face pain (leading the patient to suspect they are having sinus problems) and pain at the base of the skull (leading the patient to believe they are having neck problems). These are common migraine symptoms and not considered atypical.

Atypical signs or symptoms warranting urgent evaluation include:

The most common reasons for failure of migraine prevention include:

• Insufficient dose of preventive agent
• Insufficient duration of preventive trial (maximum clinical benefit may not be noted until 3 months of use at the target dose)
• Poor patient compliance
• Medication overuse

Consider reasons for failure of prevention and adjust therapy

Atypical signs or symptoms warranting imaging or additional tests include:

• Fever
• New neurological deficit
• Thunderclap headache (sudden onset of severe headache, maximum intensity immediately or within <60 seconds)
• Headache during sexual activity

• A new, first, or worst headache
• Significant change in headache characteristics
• Increasing frequency of headache attacks or loss of pain free periods
• Headache not responding to treatment
• Existing conditions that predispose to secondary headaches (e.g., pregnancy, cancer, immunosuppression, anticoagulants)
• Signs and symptoms of systemic illness (e.g., weight loss, fever, jaw claudication, hypertension)
• New or unexplained abnormalities on neurologic examination, such as papilledema (see Headache with papilledema)
• Headache that is worse while standing and better while supine (see Orthostatic headache)
• Headache triggered by coughing, sneezing, Valsalva, or similar straining maneuver (see Cough headache)
• Headache precipitated by exercise (see Exercise headache)
• Headache developing only during sleep, causing wakening (see Hypnic headache)
• “Side-locked” headache (exclusively on one side of the head)
• New-onset headache after age 50 (consider giant cell arteritis)
• Neuroimaging is not usually warranted for a patient with a history of migraine with stable headaches who has a normal neurologic exam. However, imaging may be warranted in a patient with atypical signs and symptoms or in a patient who does not fall within the strict definition of migraine (or has some additional risk factor) and does not otherwise require urgent evaluation.
• Migraine commonly presents with mid-face pain (leading the patient to suspect they are having sinus problems) and pain at the base of the skull (leading the patient to believe they are having neck problems). These are common migraine symptoms and not considered atypical.

Atypical signs or symptoms warranting urgent evaluation include:

Migraine without aura is a recurrent headache disorder with episodes lasting 4 to 72 hours. Typical characteristics of the headache are unilateral location, pulsating quality, moderate or severe intensity, aggravation by routine physical activity, and association with nausea and/or photophobia and phonophobia. Some patients also experience a premonitory phase hours or days before the headache and a resolution phase after the headache. Premonitory and resolution symptoms may include mood change, fatigue, cognitive changes, food craving, yawning, neck stiffness.Click for the current diagnostic criteria for migraine without aura from the International Classification of Headache Disorders (ICHD-3)Migraine with aura is a recurrent headache disorder that causes episodes of reversible focal neurological symptoms that usually develop gradually over 5 to 20 minutes and last for <60 minutes. A headache with the features of migraine without aura usually follows the aura symptoms. Less commonly, the headache lacks migrainous features or is completely absent. Auras are most often visual, but can also involve sensory, speech and/or language, motor, brainstem, retinal disturbances. Some patients also experience a premonitory phase hours or days before the headache and a resolution phase after the headache. Premonitory and resolution symptoms may include mood change, fatigue, cognitive changes, food craving, yawning, neck stiffness.Note: Many patients who experience migraine attacks with aura also have attacks without aura, or aura without headache.Click for the current diagnostic criteria for migraine with aura from the International Classification of Headache Disorders (ICHD-3)

Diagnose migraine

Failure to reach treatment goals may be caused by:

• Medication overuse
• Late use of medication
• Inadequate medication for degree of disability
• Poor match between medication and disabling symptoms (e.g., using oral agents for a patient with vomiting)
• Inappropriate route of administration (e.g., using oral agents for a headache in which maximum disability occurs quickly)
• Failure to use adjunctive medication (e.g., antiemetics)
• Barriers to adherence
• Inaccurate diagnosis

After correcting for any of these factors, a trial of an alternative non-specific medication should be considered.

Consider failure of treatment goals and adjust therapy

Additional tests based on clinical presentation may include:

• Erythrocyte sedimentation rate and C-reactive protein – In patients aged 50 years or older with new or changed headache patterns
• CT of the head – In patients with acute presentation of headache associated with trauma or focal neurological signs
• MRI of the head and brain with and without gadolinium contrast
• Lumbar puncture (may require consultation with a neurologist – In patients with suspected intracranial infection or intracranial hyper or hypotension. The presence of focal neurological signs, coma and/or papilledema require neuroimaging prior to lumbar puncture.

Consider additional tests based on clinical presentation

While headache is the usual reason for which patients seek treatment, non-head pain migraine symptoms (e.g. nausea, vomiting, light sensitivity, noise sensitivity) are often as or more debilitating than the head pain of migraine and should be considered.

Classify by severity of attack

ED treatment of migraine

First line per the AHS guidelines:

• Sumatriptan 6 mg subcutaneous (may repeat once in 1 hour for maximum dose of 12 mg in 24 hours)
• Many patients may not have taken a triptan before the ED visit so giving a triptan may be a reasonable option.
• Metoclopramide 10 mg IV (dose may be repeated)

or

• Prochlorperazine 10 mg IV
• Consider extrapyramidal reactions
• If IV access cannot be established, consider IM administration
• Dexamethasone 10-24 mg IM or IV once
• Dexamethasone has been shown to prevent migraine recurrence

Additional options, in no particular order, if contraindications or history of treatment failure with above options include:

• IV hydration with 0.9% normal saline, 1 L over 1 hour
• Ketorolac 15 to 30 mg IV
• May repeat ketorolac 15 to 30 mg every 6 hours or acetaminophen 1000 mg every 4 to 6 hours if needed
• Studies on ketorolac for headache have been mostly done with 30 mg doses, but recent data suggest that lower doses exhibit a ceiling effect and may be effective
• Acetaminophen 1000 mg PO or IV
• Chlorpromazine 12.5 mg IV as a slow infusion
• Consider extrapyramidal reactions
• Valproic acid 1000 mg IV
• Caution in women of childbearing potential who are not using effective contraception.
• Magnesium sulfate 1 g IV
• Extracranial nerve block(s)
• Consider dihydroergotamine (DHE)
• Most patients at this point in the treatment algorithm will have a contraindication to DHE, either because they have received a triptan in the last 24 hours or because many DHE contraindications overlap with those of triptans. However, DHE can be particularly useful for hospitalized patients with status migrainosus (once no contraindications exist) but is also sometimes used in the emergency department or outpatient settings.
• Droperidol 2.5 mg IV
• Consider QTc prolongation
• Haloperidol 1 mg IV
• Consider QTc prolongation
• Promethazine 25 mg IM
• Due to risk of severe tissue injury, including gangrene, preferred route of administration for promethazine is PO, rectal, or deep intramuscular (IM). Avoid IV. Subcutaneous is contraindicated.

Opioids are generally inappropriate for acute migraine treatment and should be carefully considered on a case by case basis. Patients already using opioids >9 days per month for headache management may have a component of medication-overuse headache. Patients should not be discharged from the emergency department with a new opioid prescription.

ED evaluation of headache

Non-contrast computed tomography (CT) of the headAn emergency non-contrast CT scan of the head is usually the initial test in evaluating headache emergencies.Additional work-up for secondary headache will depend on the clinical situation. If secondary causes of headache have been ruled out with appropriate investigations, and migraine is diagnosed, proceed to ED treatment of migraine.ED treatment of migraine

ED Management

History of present illness

• Temporal characteristics
• Headache characteristics
• Factors that aggravate or relieve headache
• Treatments tried (pharmacologic and non-pharmacologic) and relative efficacy

Past medical history

• Presence of other medical conditions associated with migraine (e.g., asthma, irritable bowel syndrome, depression, anxiety, Raynaud’s phenomenon, obstructive sleep apnea, idiopathic gastroparesis, interstitial cystitis)

Family history

• Family history of migraine or other primary headache disorder

Social history

• Recent changes in health or lifestyle

Physical examination

• Vital signs
• Evaluation of extracranial structures
• Examination of the neck in flexion versus lateral rotation for meningeal irritation
• Neurologic examination

Perform history and physical examination

Headache interferes with or prevents daily routine.

Moderate-severe

Treatment goals should be reassessed in 6 to 12 months.If goals are still met, the non-specific medication regimen should be continued. If goals are no longer met, consider reasons for failure of treatment goals and adjust therapy.

• Failure to reach treatment goals may be caused by:
• Medication overuse
• Late use of medication
• Inadequate medication for degree of disability
• Poor match between medication and disabling symptoms (e.g., using oral agents for a patient with vomiting)
• Inappropriate route of administration (e.g., using oral agents for a headache in which maximum disability occurs quickly)
• Failure to use adjunctive medication (e.g., antiemetics)
• Barriers to adherence
• Inaccurate diagnosis

Reassess in 6-12 months

Atypical signs or symptoms warranting imaging or additional tests include:

• Fever
• New neurological deficit
• Thunderclap headache (sudden onset of severe headache, maximum intensity immediately or within <60 seconds)
• Headache during sexual activity

• A new, first, or worst headache
• Significant change in headache characteristics
• Increasing frequency of headache attacks or loss of pain free periods
• Headache not responding to treatment
• Existing conditions that predispose to secondary headaches (e.g., pregnancy, cancer, immunosuppression, anticoagulants)
• Signs and symptoms of systemic illness (e.g., weight loss, fever, jaw claudication, hypertension)
• New or unexplained abnormalities on neurologic examination, such as papilledema (see Headache with papilledema)
• Headache that is worse while standing and better while supine (see Orthostatic headache)
• Headache triggered by coughing, sneezing, Valsalva, or similar straining maneuver (see Cough headache)
• Headache precipitated by exercise (see Exercise headache)
• Headache developing only during sleep, causing wakening (see Hypnic headache)
• “Side-locked” headache (exclusively on one side of the head)
• New-onset headache after age 50 (consider giant cell arteritis)
• Neuroimaging is not usually warranted for a patient with a history of migraine with stable headaches who has a normal neurologic exam. However, imaging may be warranted in a patient with atypical signs and symptoms or in a patient who does not fall within the strict definition of migraine (or has some additional risk factor) and does not otherwise require urgent evaluation.
• Migraine commonly presents with mid-face pain (leading the patient to suspect they are having sinus problems) and pain at the base of the skull (leading the patient to believe they are having neck problems). These are common migraine symptoms and not considered atypical.

Atypical signs or symptoms warranting urgent evaluation include:

Migraine-specific treatments: Migraine-specific drugs (e.g., triptans, gepants, ditans and DHE) can be used if common analgesics do not provide adequate relief. Migraine-specific drugs are more efficacious than non-specific analgesics, particularly when migraine episodes result in pronounced disability. Migraine specific treatments can be combined with anti-emetics and NSAIDs.

• Administration and dosage of triptans
• Administration and dosage of gepants
• Administration and dosage of ditans
• Administration and dosage of anti-emetics
• Current licensed neuromodulation devices for acute treatment of migraine

Start a migraine specific treatment

Non-specific medications

An individualized strategy for migraine treatment is required because no single approach is preferred for all patients.To prevent medication-overuse headache, acute treatment should be limited to ≤14 days/month for simple analgesics and ≤9 days/month for combination analgesics, triptans, ergot derivatives OR opioids.

Initiate common analgesics

• Failure to reach treatment goals may be caused by:
• Acute medication overuse
• Late use of medication
• Inadequate medication for degree of disability
• Poor match between medication and disabling symptoms (e.g., using oral agents for a patient with vomiting)
• Inappropriate route of administration (e.g., using oral agents for a headache in which maximum disability occurs quickly)
• Failure to use adjunctive medication (e.g., antiemetics)
• Barriers to adherence
• Inaccurate diagnosis

Consider reasons for treatment failure

Headache intensity is mild but patient is able to continue their daily routine with minimal alteration.

Mild

Atypical signs or symptoms warranting imaging or additional tests include:

• Fever
• New neurological deficit
• Thunderclap headache (sudden onset of severe headache, maximum intensity immediately or within <60 seconds)
• Headache during sexual activity

• A new, first, or worst headache
• Significant change in headache characteristics
• Increasing frequency of headache attacks or loss of pain free periods
• Headache not responding to treatment
• Existing conditions that predispose to secondary headaches (e.g., pregnancy, cancer, immunosuppression, anticoagulants)
• Signs and symptoms of systemic illness (e.g., weight loss, fever, jaw claudication, hypertension)
• New or unexplained abnormalities on neurologic examination, such as papilledema (see Headache with papilledema)
• Headache that is worse while standing and better while supine (see Orthostatic headache)
• Headache triggered by coughing, sneezing, Valsalva, or similar straining maneuver (see Cough headache)
• Headache precipitated by exercise (see Exercise headache)
• Headache developing only during sleep, causing wakening (see Hypnic headache)
• “Side-locked” headache (exclusively on one side of the head)
• New-onset headache after age 50 (consider giant cell arteritis)
• Neuroimaging is not usually warranted for a patient with a history of migraine with stable headaches who has a normal neurologic exam. However, imaging may be warranted in a patient with atypical signs and symptoms or in a patient who does not fall within the strict definition of migraine (or has some additional risk factor) and does not otherwise require urgent evaluation.
• Migraine commonly presents with mid-face pain (leading the patient to suspect they are having sinus problems) and pain at the base of the skull (leading the patient to believe they are having neck problems). These are common migraine symptoms and not considered atypical.

Atypical signs or symptoms warranting urgent evaluation include:

• Relieves attack severity within 2 hours
• Restores ability to function
• Minimizes use of back-up and rescue medications
• Optimizes self-care
• Reduces subsequent use of medical resources
• Limits or eliminates adverse effects

Treatment goals for acute migraine symptoms

These devices are FDA cleared but efficacy has not been evaluated by the FDA.

Current licensed neuromodulation devices for migraine prevention

Adjunctive therapy for migraine in an adult may include:

• Acupuncture
• Biofeedback

• Cognitive behavior therapy
• Relaxation training
• Support groups

Adjunctive therapy

Access resources about picking a preventive migraine treatment here.

• Therapeutic opportunities that allow a single drug to prevent migraine episodes while also treating a coexisting condition should be considered.
• Patient preference should be respected (e.g., some preventive agents may increase weight, decrease weight, or cause sedation which may or may not be desirable).
• Consider contraception in women of childbearing age.
• Migraine prevention is often discontinued during pregnancy.

Selecting a preventive agent

While no guidelines exist, it is good practice to discuss tapering or discontinuing a preventive agent after ~1 year of “good” migraine control.However, a patient who previously had frequent disabling episodes and has found a successful preventive agent may choose to continue prevention for a longer period of time or sometimes indefinitely.

Continue preventive agent

• Decrease episode frequency, severity, and duration
• Improve responsiveness to treatment of acute attacks
• Improve function and decrease disability
• Decrease cost of migraine management

Realistic expectations should be discussed ahead of time to prevent frustration. Prevention is considered successful if headache frequency is decreased by ≥50% following a 3-6 month treatment trial.

Goals of migraine prevention

While no guidelines exist, it is good practice to discuss tapering or discontinuing a preventive agent after ~1 year of “good” migraine control.However, a patient who previously had frequent disabling episodes and has found a successful preventive agent may choose to continue prevention for a longer period of time or sometimes indefinitely.

Continue preventive agent

• Decrease episode frequency, severity, and duration
• Improve responsiveness to treatment of acute attacks
• Improve function and decrease disability
• Decrease cost of migraine management

Realistic expectations should be discussed ahead of time to prevent frustration. Prevention is considered successful if headache frequency is decreased by ≥50% following a 3-6 month treatment trial.

Goals of migraine prevention