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Migraine

Matthieu DeClerck, MD and Tarlan Hedayati, MD
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30:14

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Patients with migraines often present to the urgent care in search of relief. Tarlan and Matt discuss caring for these patients from initial approach to treatment strategies.

Pearls:

  • Lead with antiemetics when treating migraines in the UC.  They treat both the migraine and the associated nausea/vomiting.
  • Consider NSAIDS (ketorolac or ibuprofen) as second-line therapy.
  • Haloperidol and droperidol have analgesic + anti-emetic properties and are excellent third-line choices.

Case 

A 35 year old woman presents to UC with a headache for 2 days that she describes as typical of her “migraines.” She has a PCP who had made the diagnosis in the past. She usually takes acetaminophen or ibuprofen with relief of symptoms, but it has been ineffective this time. She has associated photophobia, phonophobia, and 1 episode of emesis. Her neurological exam is normal. 

 

  • Approach to patients with a prior history of migraines who present with a headache:
    • The goal is to make sure there isn't anything nefarious as the cause of their headache and to rapidly provide analgesia.
    • History
      • Use open-ended questions to determine whether this headache is different from their typical migraines. Verbiage should give the patient an opportunity to tell you if there’s something different going on. 
        • For example, “How is this headache different from your prior migraines?” instead of, “Is this just like your prior migraines?”
      • Important questions to ask:
        • Is the quality of the headache similar to prior?
          • Is the location of the headache different? Are the associated symptoms different?
          • A headache with a different quality is more concerning than a headache with the same qualities but increased intensity. 
        • Was the headache maximal at onset or was there associated fever?
        • Was there preceding trauma? Syncope? Onset with exertion? New neuro changes? Anticoagulation?
        • What medications have they taken at home and when? What has worked in the past?
    • Exam
      • An abbreviated neuro exam should be done as these patients are in pain. Avoid flashing lights in the eyes.
      • Gait testing can quickly give you information about balance, strength, and coordination.
      • Sensory exam can be very general, testing light touch primarily.
      • Cranial nerve exam can be done quickly, with much of the assessment observed while talking to the patient.
  • Therapies we can use in the UC and/or ED.
    • Try to put the patient in a relatively quiet area that is not under a bright light. 
    • Start with PO acetaminophen or ibuprofen (unless the patient is vomiting or has already failed a home trial of it). 
    • Decide your strategy:  IV or IM?
      • Most of the medications that we would use can be given in both routes. 
      • Hedayati’s strategy is to place an IV, as it allows her easy access if patients fail the initial medication choice.
    • IV fluids?
      • IV fluids do not improve headache symptoms and should only be used to treat dehydration.
    • O2 therapy?
      • Only helpful for patients with cluster headaches.
    • First-line:  prochlorperazine (Compazine) or metoclopramide (Reglan)
      • Lead with antiemetics; they treat both the migraine and the associated nausea/vomiting.
      • Dosing for both is 10 mg IV or IM
        • Have analgesic and antiemetic effects. 
        • Give slowly (over 2-5 minutes) to prevent extrapyramidal side (EPS) effects. 
          • Akathisia can occur in up to ⅓ of patients. 
          • If it develops, treat EPS with diphenhydramine. 
    • Second-line:  NSAIDS (ketorolac or ibuprofen)
      • IV ketorolac is helpful if the patient is vomiting, but has the same efficacy as ibuprofen.
      • Dosing of ketorolac is 10-15 mg IV or IM.
    • Third-line:  haloperidol (5 mg IV) or droperidol (2.5 mg IV)
      • Analgesic + anti-emetic properties.
    • Triptans? 
      • The efficacy of sumatriptan is inversely proportional to duration of the HA, and most patients don't present immediately to the UC.
      • If patients are already on triptans, they have usually taken it and it has failed so not particularly useful. 
      • If not on triptans, can give SQ but then need to be mindful of side effects like chest pain. 
      • ED studies comparing sumatriptan to antidopaminergic agents show them to be less efficacious. 
    • Opiates
      • Reserved for intractable pain that has failed other first line therapies.
    • Nerve blocks
      • Link to Nov 2019 UCRAP  “Nerve Blocks for HA Treatment” (paid subscriptions only)
      • Link to YouTube video demonstration
      • Sphenopalatine block 
        • When it works, it's like magic.  
        • Long, cotton-tipped applicator saturated with 4% lidocaine is inserted intranasally and applied to the lateral posterior wall of the nasal cavity. Can also teach patients how to do this!
      • Occipital nerve
        • Great for diagnosing and treating occipital neuralgia.
        • Locate the occipital protuberance and the mastoid. About halfway between the two is the greater occipital nerve. Inject 2-3cc of lidocaine or bupivacaine.
      • Cervical nerve
        • Best for tension headaches.
        • 2 mL of bupivacaine or lidocaine is injected 1-1.5 inches into the paraspinous muscles bilaterally located 2-3 cm from the spinous process of C6 or C7.

 

 

References:

  1. D'Souza R, et al. Effects of prophylactic anticholinergic medications to decrease extrapyramidal side effects in patients taking acute antiemetic drugs: a systematic review and meta-analysis. Emerg Med J. 2018 May;35(5):325-331 PMID: 29431143
  1. Cady R, et al. A double-blind, placebo-controlled study of repetitive transnasal sphenopalatine ganglion blockade with tx360(®) as acute treatment for chronic migraine. Headache. 2015 Jan;55(1):101-16. PMID: 25338927
  1. Friedman B, et al. Diphenhydramine as Adjuvant Therapy for Acute Migraine: An Emergency Department-Based Randomized Clinical Trial. Ann Emerg Med. 2016 Jan;67(1):32-39.e3. PMID: 26320523
  1. Gaffigan M, et al. A Randomized Controlled Trial of Intravenous Haloperidol vs. Intravenous Metoclopramide for Acute Migraine Therapy in the Emergency Department. J Emerg Med. 2015 Sep;49(3):326-34.PMID: 26048068

  2. Friedman B. Migraine in the Emergency Department. Neurol Clin. 2019 Nov;37(4):743-752.PMID: 31563230

  3. Balbin JE, Nerenberg R, Baratloo A, Friedman BW. Intravenous fluids for migraine: a post hoc analysis of clinical trial data. Am J Emerg Med. 2016 Apr;34(4):713-6. PMID: 26825817

William L. -

I went for a walk yesterday and I decided to listen to UC Rap since I was alone. I am so glad I did! I listened to the migraine episode and it will change my practice. What an excellent discussion of migraine treatment. It is not often that a 45 minute walk changes the way I practice medicine. Thank you. I rushed home and watched the excellent you tube video on the the blocks discussed so I can use them at the next opportunity. I am really hoping a patient with migraine comes in to the clinic for my shift tomorrow.
Keep up the great work.
Bill Leeson, MD
Santa Fe, NM

Mike W., MD -

Thx for the comment Bill... so good to hear!!
M

Wei T. -

Thank you for another great segment. For the injections, is it 2-3mL each side or total?

Mike W., MD -

From Matt DeClerck:
2-3 each side
Thx

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