Migraine headache

Background

Definition: Migraine Headache without Aura

• At least 5 attacks of headache fulfilling the following criteria:
  • HA attacks lasting 4–72 hr (untreated or unsuccessfully treated) (>1 h for children)
  • HA 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 HA at least one of the following occurs:
    • Nausea and/or vomiting
    • Photophobia and phonophobia (may be inferred from behavior)
  • Not attributed to another disorder

Diagnosis

• If pt has at least 4 of the following 5 "POUNDing" features LR of migraine is 24

1. Pulsatile quality
2. duration of 4-72 hOurs
3. Unilateral
4. Nausea or vomiting
5. Disabling in quality

DDX

Headache

Common

• Migraine headache
• Tension headache
• Cluster headache

Killers

• Meningitis/encephalitis
  • Neoplastic meningitis
• Myocardial ischemia
• Retropharyngeal abscess
• Intracranial Hemorrhage (ICH)
  • SAH / sentinel bleed
• Acute obstructive hydrocephalus
• Space occupying lesions
• CVA
• Carbon monoxide poisoning
• Basilar artery dissection
• Preeclampsia
• Cerebral venous thrombosis
• Hypertensive emergency
• Depression

Maimers

• Giant cell arteritis of temporal artery (temporal arteritis)
• Idiopathic intracranial hypertension (Pseudotumor Cerebri)
• Acute Glaucoma
• Acute sinusitis
• Cavernous sinus thrombosis or cerebral sinus thrombosis
• Carotid artery dissection

Others

• Mild traumatic brain injury
• Trigeminal neuralgia
• TMJ pain
• Post-lumbar puncture headache
• Dehydration
• Analgesia abuse
• Various ocular and dental problems
• Herpes zoster ophthalmicus
• Herpes zoster oticus
• Cryptococcosis
• Febrile headache (e.g. pyelonephritis, nonspecific viral infection)
• Ophthalmoplegic migraine
• Superior Vena Cava Syndrome

Aseptic Meningitis

• Viral
  • Varicella
  • Herpes
  • Enterovirus
  • West Nile
• Tuberculosis
• Lyme disease
• Syphilis
• Leptospirosis
• Fungal (AIDS, transplant, chemotherapy, chronic steroid use)
• Noninfectious
  • Sarcoidosis
  • Vasculitis
  • Connective tissue disease
  • Drug induced aseptic meningitis

Treatment

1. Migraine
   1. 1st line: Prochlorperazine (compazine) 10mg IV (+/- diphenhydramine 12.5 mg IV)
      1. Most effective therapy
   2. 2nd line:
      1. Metoclopramide (reglan) 10mg IV
      2. DHE 1mg IV over 3min
         1. Consider metoclopramide or prochlorperazine as pre-treatment antiemetic
         2. Contraindications: pregnancy, cardiovascular disease, HTN
      3. Triptans
         1. Contraindications: cardiovascular disease, use of DHE in previous 24hrs
   3. Ketorolac

See Also

• Headache
• Headache Red Flags

Source

• International Headache Society Diagnostic Criteria
• Detsky et. al, JAMA '06 Does this Patient with a Headache have a Migraine or need Neuroimaging?