Head-Splitting Decisions: Tackling Migraines in the ED

-Case-
It’s a busy Thursday evening in the ED, and a 36-year-old female presents with a severe headache. She describes a history of similar episodes and reports that this headache began gradually over the past 12 hours. It is located on the right side of her head; the pain is throbbing and is associated with nausea and photophobia. She denies any recent trauma, fever, neck stiffness, or neurologic symptoms. Over-the-counter ibuprofen hasn’t helped, and her neuro exam is normal.

Now, when is a headache not just a headache? What’s the best way to get this patient feeling better?

-Evaluation-
Migraines are a very common ED presentation, and this patient’s pain pattern and lack of neuro findings points us towards a classic migraine pattern. While it is essential to consider other causes, not every headache requires an extensive workup

• Classic Features of Migraine: gradual onset of unilateral, throbbing pain lasting 4-72 hours, often associated with nausea, vomiting, photophobia, and phonophobia.
  • About 75% of people with migraines will have prodromal symptoms (think anxiety, neck stiffness, depression, yawning) while only about 25% will have true aura symptoms such as sensory abnormalities or changes in vision
• Key Considerations for Secondary Causes: new-onset headaches in patients (especially in those >50 years old), any abrupt onset or “thunderclap” pain, associated systemic symptoms (fever, weight loss), neurologic deficits like weakness or confusion/AMS, or a recurrent headache worse in the morning that improves throughout the day
  • In our patient above, the lack of these concerning features points us to a migraine rather than something more insidious
• Testing and Imaging: routine neuroimaging is not indicated for patients with a clear migraine without the concerning features we just discussed

-Management-
Our goal: rapid relief and getting the patient back on their feet! With time, you’ll develop your own set of medications, but some options to consider while figuring out your favorite regimen include some of these:

• First-Line Medications:
  • Metoclopramide or Prochlorperazine: effective for pain relief and often combined with oral diphenhydramine to prevent extrapyramidal symptoms. EPS are pretty rare and can typically be avoided if you push these medications slowly, but some physicians prefer to just give Benadryl “prophylactically”
  • Ketorolac: NSAIDs like ketorolac are a strong adjunct for pain management; many attendings will include this medication along with one of the above.
  • For these medications, IV is the way to go! These meds as PO don’t work nearly as well…
• Adjuncts for Severe/More Complex Cases:
  • Dexamethasone: though not particularly helpful for acute relief, this med has been shown to reduce the rates of migraine recurrence after discharge
  • Magnesium sulfate: can be considered in pregnant patients or those with aura
• These are all great options until you develop your own “go-to” set of medications. This is often a product of the institution you train at, but my personal favorite regimen is Reglan, Toradol, and Benadryl!

-Fast Facts-

• Be reassured by classic migraine features (gradual onset, unilateral, throbbing pain with nausea and photophobia) in patients with a known history of migraines
• Investigate secondary causes in cases with new or atypical headache features, systemic symptoms, or neurologic deficits
• First-line treatment options for acute migraines in the ED include Reglan/Compazine (+/- Benadryl) and Toradol
• Never (and we really mean never) opt to give your migraine patients opiate medications for their headaches!
• Discharge planning is key! Ensure the patient has a plan with appropriate outpatient medications – if not, make sure they have prompt PCP follow-up!

Want to read more about this topic? Click ✨here✨ to read our in-depth Study Guide!

Cheers,

Tamir Zitelny, MD