Ver el código de «Migraine headache»

==Background<ref>Ashina, Messoud. Migraine. The New England Journal of Medicine. 2020;383(19): 1866-1876</ref>==
*Female-to-male ratio of 3:1
*Tends to be familial
**Heritability estimated to be approximately 42%
*Pathogenesis is thought to involve the trigeminovascular system, which when activated results in parasympathetic dilation of intracranial arteries. 
*Migraine without aura most common (~80%)<ref>Russi CS, Walker L. Headache. In: Walls RM, Hockberger RS, Gausche-Hill M, et al., eds. Rosen’s Emergency Medicine: Concepts and Clinical Practice. 9th ed. Philadelphia, PA: Elsevier Saunders; 2018:(Ch) 17:153–159.</ref>
===Definition: Migraine Headache without Aura<ref>International Headache Society Diagnostic Criteria</ref>===
*At least 5 attacks of headache fulfilling the following criteria:
**headache attacks lasting 4–72 hr (untreated or unsuccessfully treated) (>1 h for children)
**headache has at least 2 of the following characteristics:
***Unilateral location
***Pulsating quality
***Moderate or severe pain intensity
***Aggravation by or causing avoidance of routine physical activity
**During headache at least one of the following occurs:
***Nausea and/or vomiting
***Photophobia and phonophobia (may be inferred from behavior)
**Not attributed to another disorder

===Definition: Migraine Headache with Aura===
*At least two attacks fulfilling criteria A and B
*Criteria A: One or more of the following fully reversible aura symptoms:
**visual
**sensory
**speech and/or language
**motor
**brainstem
**retinal
*Criteria B: At least three of the following six characteristics:
**at least one aura symptom spreads gradually over ≥5 minutes
**two or more aura symptoms occur in succession
**each individual aura symptom lasts 5-60 minutes
**at least one aura symptom is unilateral
**at least one aura symptom is positive
**the aura is accompanied, or followed within 60 minutes, by headache
*Not better accounted for by another ICHD-3 diagnosis.

==Clinical Features==
''If at least 4 of the following "POUNDing" features, LR of migraine is 24''<ref>Detsky et. al, JAMA  '06 Does this Patient with a Headache have a Migraine or need Neuroimaging?</ref>
*'''P'''ulsatile quality
*'''O'''nset/duration of 4-72 hours
*'''U'''nilateral
*'''N'''ausea or [[vomiting]]
*'''D'''isabling in quality

Basilar-type migraine may be associated with fully reversible dysarthria, vertigo, tinnitus, decreased hearing, double vision or ataxia

==Differential Diagnosis==
{{Headache DDX}}

==Evaluation==
===Workup===
*Consider pregnancy test (for medication selection)

===Diagnosis===
*Diagnosis is normally clinical
**Make sure you considered other causes of emergent [[headache]]

==Management==
*1st line: [[Prochlorperazine]] (compazine) 10mg IV (+/- [[diphenhydramine]] 12.5mg IV)<ref>Coppola et al, Annals of Emergency Medicine, Nov 1995. Randomized, Placebo-Controlled Evaluation of Prochlorperazine Versus Metoclopramide for Emergency Department Treatment of Migraine Headaches.</ref>
**Most effective therapy 
*2nd line:
**[[Metoclopramide]] (reglan) 10mg IV 
**DHE 1mg IV over 3min
***Consider [[metoclopramide]] or [[prochlorperazine]] as pre-treatment antiemetic
***Contraindications: pregnancy, cardiovascular disease, hypertension 
**Triptans
***Contraindications: cardiovascular disease, use of DHE in previous 24hrs
*[[Ketorolac]]
*[[Steroids]]
**[[Dexamethasone]] to prevent recurrence 48-72 hours post-ED discharge, if history of migraines and recurrent headaches<ref>Colman et al Parenteral dexamethasone for acute severe migraine headache: meta-analysis of randomised controlled trials for preventing recurrence. BMJ 2008 Jun.;336(7657):1359–1361</ref>
*** 10 mg IV single dose is commonly accepted regimen, 4 mg IV dose was shown to be as efficacious in a follow up study. <ref>Friedman BW, Solorzano C, Kessler BD, Martorello K, Lutz CL, Feliciano C, Adler N, Moss H, Cain D, Irizarry E. Randomized Trial Comparing Low- vs High-Dose IV Dexamethasone for Patients With Moderate to Severe Migraine. Neurology. 2023 Oct 3;101(14):e1448-e1454.</ref>

{{Non-specific headache treatment}}

===Migraine Prophylaxis===
*Typically not the role or responsibility of the EP
*Lifestyle changes (avoiding caffeine, smoking and food triggers)
*If inclined to give Rx, give very short supply and ensure proper follow up
*Consider drug side effects, interactions, cormorbidities
*American Academy of Neurology and American Headache Society level A drug options, starting dosages<ref>Loder E et al. The 2012 AHS/AAN Guidelines for Prevention of Episodic Migraine: A Summary and Comparison With Other Recent Clinical Practice Guidelines. 2012 American Headache Society. Headache 2012;52:930-945.</ref>
**[[Valproate]]/divalproex 250 mg q12
**[[Metoprolol]] 25 mg q12
**[[Propranolol]] 30 mg q8
**[[Timolol]] 10 mg q12
**[[Topiramate]] 25 mg QHS x1, then 25 mg q12

==Disposition==
*Outpatient


<div style="display:none">
<!-- SMW MedicationDose annotations for migraine headache medications -->
{{MedicationDose|drug=Prochlorperazine|dose=10 mg IV|route=IV|context=1st line abortive (most effective)|indication=Migraine headache|display=Prochlorperazine (Compazine)|notes=Give with diphenhydramine to prevent akathisia/EPS}}
{{MedicationDose|drug=Diphenhydramine|dose=12.5-25 mg IV|route=IV|context=Adjunct to prevent akathisia/EPS|indication=Migraine headache}}
{{MedicationDose|drug=Metoclopramide|dose=10 mg IV|route=IV|context=2nd line abortive|indication=Migraine headache|display=Metoclopramide (Reglan)}}
{{MedicationDose|drug=Ketorolac|dose=15-30 mg IV|route=IV|context=NSAID adjunct|indication=Migraine headache}}
{{MedicationDose|drug=Dexamethasone|dose=10 mg IV|route=IV|context=Prevent recurrence (48-72h post-discharge)|indication=Migraine headache|notes=NNT 8-9 for recurrence prevention; consider if history of recurrent migraines}}
{{MedicationDose|drug=Magnesium sulfate|dose=1-2 g IV over 15-30 min|route=IV|context=Adjunct (especially for aura)|indication=Migraine headache|notes=May be particularly effective for migraine with aura}}
</div>
==See Also==
*[[Headache]]
*[[Headache (peds)]]
*[[Postpartum headache]]
*[[Headache during pregnancy]]
*[[CT Before LP]]

==References==
<references/>

[[Category:Neurology]]