1. Migraine Headache – Update on Diagnosis & Treatment
Herbert L. Muncie, Jr., M.D.

2. What is the diagnosis?
Sarah, a previously very healthy 14 year old female complains of a severe headache & nausea. It is the start of the Thanksgiving holiday and all she wants to do is lay on the sofa.
PMH
H. flu meningitis age 7 months
Car motion sickness as a child
Family history positive for migraines – maternal grandmother & mother

3. Diagnosing Migraine Headache
Any severe or recurrent headache most likely is a form of migraine
Almost all patients will have family history of migraines or at least “sick” headaches
Only 15% have preceded or accompanied focal neurologic symptoms
Usually visual
Vision loss or distortion in one eye – ‘ocular migraine’
“Classic migraine”

4. Sarah Spent most of Thanksgiving holiday resting on the sofa
Diagnosed with onset of migraine headaches

5. Recurrent Headaches Primary Migraine Tension Cluster
Other benign – cough, cold temperature, post coital, exertion

6. Recurrent Headaches Secondary (pain from complications)
Intracranial tumor
Intracranial aneurysm
Intracranial A-V malformation
Temporal arteritis 6

7. Migraine with aura – Criteria*
At least 2 attacks with 3 of the following:
Fully reversible aura symptoms
At least 1 aura symptom develops gradually during more than 4 minutes or 2 symptoms occur in succession
Any aura symptom lasts less than 60 minutes
Headache follows the aura within 60 minutes
*International Headache Society

8. Migraine with aura Visual aura common
Slowly evolving scintillating scotoma that moves or passes through visual field
Duration of aura – 22 minutes
Should not be called ocular migraine if bilateral eye involvement
Just call them migraine with aura

9. Visual aura rating scale (VARS)
Visual Symptom
Risk Score
Duration minutes 3
Develops gradually over 5 min 2
Scotoma
Zigzag line (fortification)
Unilateral (homonymous) 1
MIGRAINE with AURA DIAGNOSIS
≥ 5

10. Migraine with aura – vascular risk?
Migraine with aura is associated with 2 fold risk of ischemic stroke & cardiovascular event
Absolute risk is low (4 per women years)
May be indication for aggressive treatment of other risk factors
Unclear if more intense treatment & prevention of migraines will alter the risk

11. Migraine without aura – Criteria*
At least 5 attacks (bunch of them)
Lasting 4-72 hours untreated or unsuccessfully treated (didn’t just go away quickly)
Must have one of these to be migraine:
Nausea or vomiting
Photophobia
Phonophobia
*International Headache Society

12. Migraine without aura – Criteria*
Then usually have at least 2 of these:
Unilateral pain
Throbbing/pulsating
Aggravation on movement
Moderate or severe intensity
And of course to be sure not something else:
H & P does not suggest organic disorder
H & P suggests an organic disorder which is then ruled out
An organic disorder is present but attacks do not occur for the 1st time in close time to the disorder
*International Headache Society

13. Diagnosing the acute headache
The classification criteria are best suited for a between-attack assessment of their typical headache
However, they are often used for the acute attack
Once acute pain relieved, take time to make an accurate diagnosis
Up to 1/3 of ED patients cannot be assigned a diagnosis
Despite a through questionnaire-based assessment

14. ER Clinical Decision Rule
“ID Migraine” – three features
Sensitivity to light
Nausea or vomiting
Disabling intensity of headache
0 - 1 positive - low probability
If 2 positive higher probability of migraine
Criteria focus on typical attacks not the current acute attack

15. Epidemiology - Migraine
Can start at any age, however,
Peak incidence of onset is mid-adolescence (age 13-16)
History of colic or motion sickness support Dx
Median frequency - 1.5/month
Greater increase in prevalence with aging in women
Females - 6.4% age ; 17.3% age
Males % age ; 5.0% age 18 – 29
Usually more severe in women

16. Pathophysiology Migraine is a primary neural event
Something lowers threshold for a cortical spreading depression (CSD)
Which causes regional hypoperfusion (aura)
Release of proinflammatory neurochemicals
Neural event results in vasodilation
Which leads to pain & more nerve activation
Migraine headache is not a primary vascular event

17. Why does it hurt? Substance of brain is largely insensate
Pain could come from:
Cranial blood vessels
Trigeminal innervations of vessels
Reflex connection of trigeminal system with cranial parasympathetic flow
No clear explanation for why it hurts

18. Testing Indications*
Laboratory tests not helpful or needed to make the diagnosis
EEG not indicated as routine evaluation
Neuroimaging guidelines
Typical migraine with normal neurologic exam
Neuroimaging not warranted (SOR-B)
Insufficient evidence regarding imaging in presence of neurologic symptoms (SOR-C)
*U.S. Headache Consortium (2000)

19. Neuroimaging - EBM
For non-acute HA with unexplained abnormal finding on neurologic examination – obtain neuro image (SOR-B)
If atypical features or headache does not fulfill definition of migraine – lower the threshold for obtaining imaging (SOR-C)
CT vs. MRI?
Insufficient data to recommend MRI compared to CT in evaluation of migraine or other nonacute headache (Grade C)

20. Red Flags! Strongly consider neuroimaging if New onset > age 50
Thunderclap onset
Focal and nonfocal symptoms
Abnormal signs
Headache with change in posture
Valsalva headache
HIV or cancer diagnosis

21. Prodrome (before headache)
Some patients experience symptoms hours to days before the headache (prodrome)
Fatigue
Inattentiveness/confusion
Restlessness, elation, +/- irritability
Insomnia +/- depression
Joint pain
Hunger or food craving
Yawning

22. Treatment Goals of treatment
Reduce frequency, severity, & duration of headaches
Improve quality of life (QOL)
Avoid acute medication escalation
Treatment Guidelines are based upon having a specific diagnosis
Often difficult initially to make specific Dx
Therefore, significant uncertainty about ‘best’ initial treatment

23. Treatment - Migraine
The brain of patients with migraines does not tolerate peaks or troughs of life
Patients should get:
Regular sleep
Go to bed and awaken same time every day
Regular meals
Eat same time every day
Never skip meals – fasting associated with precipitating headache
Regular exercise
Avoid peaks of stress, troughs of relaxation
Avoid unique dietary triggers

24. Migraine & Diet - EBM
Frequency, duration & severity are NOT increased by dietary choices (SOR-A)
Cheese, alcohol, chocolate, citrus are not universal triggers
Low-fat diet reduced frequency of migraines (SOR-B)

25. Migraine & Supplements - EBM
Supplements reduced frequency & intensity
Riboflavin – 400 mg qd
Effect begins at 1 month, 3 months
Magnesium – 600 mg qd
Diarrhea common - almost 20%
360 mg qd during luteal phase reduced menstrual migraine
Others
Butterbur mg/d
CoQ mg/d
Feverfew mg/d
National Guideline Clearing House
SOR – A
Answer to TQ#2

26. 27
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Question
22 yo female presents with throbbing headache, nausea, photophobia for 5 hours. BP 116/76, P 86. Which of these treatments would be appropriate for her?
Ketorolac (Toradol®) 60 mg IM
Metoclopramide (Reglan®) 20 mg IV
Prochlorperazine (Compazine®) 10 mg IV
D.H.E mg IV
Sumatriptan (Imitrex®) 6 mg SQ

27. Treatment of Acute Pain
NSAID (SOR-A)
Ketorolac (Toradol®) – 10 mg oral, 60 mg IM, or 30 mg IV(SOR-C)
Combinations
Isometheptene mucate, dichloralphenazone and acetaminophen (Midrin®)
Butalbital has not been effective in controlled trials (butalbital/acetaminophen/caffeine- 50/325/40 Fioricet®, butalbital/ASA/caffeine-50/325/40 Fiorinal®)
Answer to TQ#1

28. Treatment of Acute Pain
NSAIDs – more effective when:
Taken early
With adequate initial dose
Combined with antiemetic
ASA 1000 mg
Combined with metoclopramide IM (Reglan®) reduces nausea/vomiting but not better pain control
Answer to TQ#1

29. Treatment of Acute Pain
IV fluids may benefit patients, although benefit is not well established
Unlikely to be harmful especially in patients with persistent GI symptoms
Parenteral therapy preferred due to gastric stasis & delayed absorption of oral medications
Answer to TQ#1

30. Treatment of Acute Pain
Droperidol (Inapsine®) probably most effective of dopamine agonists
Pain relief at 2 hours approaching 100%
Ideal dose – 2.5 mg IV
FDA warning about QT prolongation

31. Treatment of Acute Pain
Prochlorperazine (Compazine®) 10 mg IV
Effective with diphenhydramine (Benadryl®) – 25 mg IV [Friedman 2008]
Superior to SC sumatriptan in ED setting [Kostic 2010]
Children 0.15 mg/kg IV over 15 minutes (max 10 mg)
If EPS develop give diphenhydramine 1mg/kg (max 50 mg)
Randomized blinded trial of IV Compazine (10 mg with mg Benadryl IV) vs SC sumatriptan (6 mg) superior. Also probably less costly overall. [Kostic 2010]
Although time for IV insertion and patient acceptance may alter the decision process.

32. Treatment of Acute Pain
Metoclopramide* (Reglan®)
IV – monotherapy mg IV
IM – 10 mg adjunct to other therapies (SOR-C)
* FDA boxed warning 2/26/09 – Long-term or high-dose use of metoclopramide has been linked to tardive dyskinesia.

33. Treatment of Acute Pain
Ergot alkaloids
Dihydroergotamine (D.H.E. 45®) – 1 mg IM/IV/SC
Since it may cause nausea, more effective with metoclopramide (Reglan®) to reduce nausea
Nasal spray effective
Ergotamine/caffeine (1/100) (Cafergot®)
Little evidence effective alone
High risk of overuse & rebound headache

34. Treatment of Acute Pain
Sodium valproate (Depacon®)
500 – 1000 mg in 10 ml normal saline IV over 30 min
May be effective but less than prochlorperazine (Compazine®)

35. Treatment of Acute Pain
Complementary medicine
Topical menthol 10% was more effective at complete pain relief than placebo at 2 hours (38.3% vs 12.1%) [Haghighi 2010]
10% solution of menthol crystals in ethanol
Forehead and the temporal area most painful are washed with tap water
After drying 1 ml is applied with sponge on a surface area of 5 x 5 cm
Can be reapplied in 30 min

36. Treatment of Acute Pain - EBM
Patients with substantial disability will benefit from serotonin 5-HT1B/1D agonists (‘triptans’)
SOR – A
Clinical Evidence

37. Triptan Efficacy
No one triptan is superior in all pain relief parameters
Use one triptan for 2-3 attacks before abandoning that medication
If one does not work try another one
Answer to TQ#3

38. How is pain relief measured?
Was pain better within 2 hours?
Did the pain go away at 2 hours?
Did the pain stay away for at least hours? (No immediate recurrence)
Did the patient consistently obtain pain relief from that medication?

39. Oral Triptan Efficacy Was pain better within 2 hours?
55-65% of patients experience improvement at 2 hours
Can be repeated in 1 – 2 hours if partial response

40. Oral Triptan Efficacy Did pain go away within 2 hours?
25-35% of patients are pain free at 2 hours

41. Oral Triptan Efficacy Did pain stay away for 24 hours?
Freedom from pain at 2 hours, no rescue medication, no recurrence of pain in 24 hours
% of patients have sustained freedom from pain

42. Oral Triptan Efficacy Intra-patient Consistency?
The same patient experiences pain relief with the same medication
Rizatriptan (Maxalt®) has highest intra-patient consistency of the oral medications

43. Sumatriptan (Imitrex®) – Parenteral
6 mg SC
Pain decreased within 2 hours - 76%
Pain gone within 2 hours - 48%
Consistent pain relief for that patient - 90%
In ER best candidates are those with previous response to this treatment
Adverse events more frequent than with oral medication
And more intense

44. Sumatriptan (Imitrex®) – Parenteral
Cutaneous allodynia - sensation of pain in response to normally non-toxic touch stimuli (e.g. brushing hair, taking shower, putting hair in ponytail)
Presence of cutaneous allodynia associated with reduced response to SC sumatriptan
Needle-free injection available (Sumavel® DosePro™)
Causes as much pain as needle & more swelling, bruising & bleeding at site

45. Triptans (Medical Letter 2008)
Onset of action
Elimination half-life
Almotriptan (Axert®)
min
3 - 4 hours
Eletriptan (Relpax®)
Frovatriptan (Frova®)
~ 2 hrs
~ 25 hrs
Naratriptan (Amerge®)
1 - 3 hrs
~ 6 hrs
Rizatriptan (Maxalt®)
2 - 3 hrs
Sumatriptan (Imitrex®)
tablets
nasal spray
min
SC injection
~ 10 min
Zolmitriptan (Zomig®)

46. 27
250
Question
22 yo female presents with throbbing headache, nausea, photophobia for 5 hours. BP 116/76, P 86. Which of these treatments would be appropriate for her?
Ketorolac (Toradol®) 60 mg IM
Metoclopramide (Reglan®) 20 mg IV
Prochlorperazine (Compazine®) 10 mg IV
D.H.E mg IV
Sumatriptan (Imitrex®) 6 mg SQ 46

47. Triptans – Side Effects
Tingling
Paresthesias
Warmth head, neck, chest & limbs
Nasal spray associated with taste disturbance

48. Triptans – Cautions
Contraindicated with CAD, uncontrolled hypertension or cerebrovascular disease, hemiplegic migraine
Should not be taken within 24 hrs of another triptan or ergotamine-containing/ergot-type medication
Taking them with an SSRI or SNRI can cause life-threatening serotonin syndrome

49. Combining Medications
Sumatriptan 85 mg & Naproxen 500 mg (Treximet®) more effective than either alone for acute pain relief
Unknown effect of taking 2 separate pills (not tested)
The combination may have some increased benefit in mild/moderate pain but no evidence of need for fixed dose combination (Medical Letter 2008)

50. Early Recurrence
Up to 75% of patients will experience a recurrence of pain within 48 hours
Naproxen (500 mg) or sumatriptan (100 mg) equally effective treating the recurrence [Friedman 2010]
Naproxen prophylactically can prevent recurrence (NNT – 3)
Triptans should not be used prophylacticly

51. Preventing Early Recurrence
Parenteral dexamethasone (10-25 mg IV)
Produced 26% relative reduction in recurrence within 72 hours [Colman 2008]
Modest benefit in the ED – prevented 1 in 10 patients from experiencing moderate or severe recurrence [Singh 2008]
Later trials failed to find benefit with oral dexamethasone or prednisone

52. Acute Pain & Parenteral Opioids
Should not be used as 1st line therapy
International Headache Consortium
Canadian Association of Emergency Physicians
American Academy of Neurology
Meperidine (Demerol®) less effective than DHE and there is an:
Increased risk of sedation
Toxic metabolite with repetitive use
Friedman BW et al 2008;52:
No trials have compared morphine or hydromorphone for the treatment of migraine nor has a trial compared sumatriptan to opioid.

53. New Treatments Acute Pain
Diclofenac oral solution (Cambia®) – dissolve contents in water
Sumatriptan patch (Zelrix™) – similar levels to SC
Cambia was approved in June 2009 and is now being marketed. It has a faster tmax and onset of action compared to tablet.
Levadex approval is anticipated in 2011.

54. New Treatments Acute Pain
DHE inhaled (Levadex®) – patients not responding to triptans or more than 6 hours into headache?
Calcitonin gene-related peptide (CGRP) antagonist (telcagepant) – as effective as zolmitriptan 5 mg oral
Single-pulse transcranial magnetic stimulation (sTMS)
More effective than placebo in pain-free at 2 hours (39% vs 22%)

55. After the Migraine - Postdrome
Some patients may have:
Mood changes
“Hangover”
Tired
Weak
Disoriented
“Not right”

56. Chronic Migraine (CM) or Medication Overuse Headache (MOH)
Chronic migraine previously called ‘transformed migraine’
Consider medication overuse if ≥ 2 days/week for > 3 months analgesic use
Over period of time (months to years) can become almost daily headache
Resembles mixture of tension & migraine
Occasionally called ‘tension-vascular’
Hint – if awaken with headache consider medication overuse
MOH is more prevalent during ages and affects about 3 times more women than men.
Diagnosis of MOH is based on history and clinical presentation.
Prescriptions for acute migraine should be closely monitored to prevent overuse and to detect possible MOH earlier.
Chronic migraine treatment requires a team based comprehensive strategy. Most patients will be candidates for referral to a center specializing in the treatment of headaches. For additional information refer to:
Silberstein S et al. Epidemiology, risk factors, and treatment of chronic migraine: a focus on topiramate. Headache 2008;48:
Walker BB et al. An evidence-based practice approach. J Clin Psychol 2006:62:

57. CM Modifiable Risk Factors
Risk factor associated with increased risk of developing CM
Stressful life events
Sleep disturbance (i.e. Snoring/sleep apnea)
Obesity
Baseline headache frequency
Medication overuse
However, there is no evidence that treatment of these modifiable risk factors reduces the risk of CM. Their treatment with non-pharmacologic means would be appropriate but has not been proven in randomized trials.

58. CM & MOH Treatment Must stop acute medication to determine
Headaches will go away in a few days if medication overuse is etiology
No controlled trials of medication withdrawal
May get severe withdrawal headache
Severe withdrawal headache can be treated with short course of prednisone
Randomized trial found no difference with steroid compared to placebo
Duration of withdrawal headache varied by the previous treatments. It was 4.1 days for triptans, 6.7 days for ergots and 9.5 days for analgesics.
Relapse is high especially during the first year. Expect almost 50% of patients to relapse.

59. Preventive Medication
Candidates:
Unresponsive to acute attack medication & disabling headache
≥ 2 attacks/month
Increasing frequency of attacks
Migraines with potential neurological sequelae
Patient preference (just wants to use medication to prevent headaches)

60. 29
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Audience Question
23 y. o. female with recurrent migraine headaches. You advise starting preventive therapy. Which medication would be appropriate?
Anticonvulsant medication
Bipolar/anticonvulsant medication
Beta-blocker medication
Tricyclic medication 60

61. Prevention therapy - EBM
First line treatment should be:
Propranolol (Inderal®)
20 – 240 mg/day
Timolol
10 – 30 mg/day
Less evidence to support other beta-blockers
Amitriptyline
10 – 150 mg/day

62. Prevention therapy - EBM
First line treatment should be:
Divalproex sodium (Depakote®)
125 – 500 mg BID
Topiramate (Topamax®)
mg BID
May be as good as propranolol
Anti-epileptic drugs had greater suicidal ideation vs. placebo (0.43% vs 0.22%)
Topiramate – start with 50 mg nightly for 1 week and increase increments of 25 mg every week. Goal dosage is 50 mg bid.
May be considered in overweight patients, have epilepsy or β-blockers are contraindicated.
European Federation of Neurological Societies recommends β -blockers, topiramate and valproic acid as 1st line therapies for prevention.

63. Prevention therapy Second line (SOR-B)
Gabapentin - pregnancy category D
Carbamazepine* - pregnancy category D
* FDA Alert 12/12/07 – Dangerous or even fatal skin reactions can be caused by Carbamazepine therapy in patients with a particular HLA-B*1502 allele.

64. Prevention Therapies - EBM
Relaxation training (SOR-A)
Progressive muscular relaxation
Breathing exercises
Directed imagery
Cognitive-behavioral (SOR-A)
Combined with medication (SOR-B)
Acupuncture appears to be effective (SOR-A)
Sham acupuncture just as effective as real [Linde 2009]
Thermal biofeedback with relaxation training
For complete review of evidence-based treatments of migraine go to:
Campbell JK et al. Evidence-based guidelines for migraine headache: behavioral and physical treatments.

65. 29
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Audience Question
23 y. o. female with recurrent migraine headaches. You advise starting preventive therapy. Which medication would be appropriate?
Anticonvulsant medication
Bipolar/anticonvulsant medication
Beta-blocker medication
Tricyclic medication 65

66. Menstrual Migraine – two classes
Pure menstrual migraine without aura
Migraine without aura on days -2 to of cycle
During at least 2 of 3 cycles
Menstrual related migraine without aura
Migraine without aura as above and
At other times of the month

67. Menstrual Migraine Strongly associated with estrogen
Steep drop in estrogen just prior to menses may trigger headache
Peak incidence is 1st day and preceding day of cycle
Other clinical features
Greater severity of pain
Increased risk of nausea & vomiting
Less responsive to acute treatment

68. Menstrual Migraine Acute therapy the same as other migraines
Short-term prevention
NSAID on days -7 to +6 helped
Naproxen sodium (Anaprox®) & mefenamic acid (Ponstel®) orally have been studied
Triptans starting day -2 for 5-6 days helped
Frovatriptan (Frova®), naratriptan (Amerge®) & sumatriptan (Imitrex®) orally have been studied

69. Prognosis of Migraines
Study with 10 year follow-up of year olds at onset of migraines
40% no longer had headache
20% had episodic tension headache
20% had migraine type that was different from the original diagnosed headache
Frequency & intensity usually decreases after menopause
Two fold increased risk of CVA [Spector 2010]
May influence how aggressive to be with other therapies to reduce risk of CVA

70. Areas of Uncertainty
Causal relationship between patent foramen ovale (PFO) & migraine postulated
Closure of PFO suggested for treatment
Relationship remains uncertain & treatment of unselected patients is questionable
Intranasal lidocaine provided no relief of migraine pain in ED

71. Tension Type Headache (TTH) - Criteria
First
No vomiting – if vomiting probably a migraine
Not worsened by routine physical activity
But can have one of these clinical features
Photophobia
Phonophobia

72. TTH - Criteria
If no vomiting & only 1 other symptom - then need 2 of the following:
Pressing, tightening or non-pulsatile pain
Mild to moderate intensity of pain
Bilateral
No aggravation with movement
Diagnosis best made with use of headache diary for 4 weeks

73. TTH Underlying cause uncertain
Muscle tenderness & psychological tension associated with aggravating them
But are not clearly the cause
Susceptibility influenced by genetic factors

74. TTH Gender ration female:male 5:4 Age of onset – 25-30 years old
Peak prevalence – years old
Prevalence increases with higher educational level

75. TTH – Treatment OTC analgesic medications NSAID (prescription)
May be augmented with:
Promethazine (Phenergan®)
Diphenhydramine (Benadryl®)
Metoclopramide (Reglan®)
Efficacy tends to decrease with increasing frequency of headaches

76. Chronic Tension Headache
Tension headache that occurs
15 or more days a month
For at least 6 months

77. Treatment of Chronic Tension Headache – EBM
Beneficial (1st choice)
Amitriptyline (Start 10 – 25/day; increase up to 150 mg daily)
If no effect in 4 weeks, change therapy
Other effective therapies (second choice)
Mirtazapine (Remeron®)
Venlafaxine (Effexor®)
Likely to be beneficial
Cognitive behavioral therapy

78. Treatment of Chronic Tension Headache – Clinical Evidence
Unknown effectiveness
Acupuncture
Indian head massage
Relaxation or EMG biofeedback
SSRI
Tricyclics other than amitriptyline
Likely to be ineffective or harmful
Benzodiazepines
Regular acute pain medication
Botulism toxin

79. Cluster Headaches - Criteria
Severe unilateral, bilateral, supraorbital or temporal pain lasting minutes (untreated) and one of following on same side
Lacrimation
Rhinorrhea
Forehead or facial swelling
Ptosis
Miosis
Eyelid edema

80. Cluster Headaches - Criteria
Sense of restlessness (93% patients) or agitation
Prefer to be erect & move about
5 attacks with frequency of 1-8 on any given day from no other cause
75% of attacks last < 60 minutes

81. Cluster Headaches Male : female – 2.1 : 1 Peak onset in 40’s
60% right sided
Probably most severe pain known to humans
Female patients describe attacks as worse than childbirth

82. Episodic cluster
≥ 2 cluster periods lasting days & separated by pain-free remission ≥ 1 month
Absence of aura, nausea, vomiting
Distinguishes it from migraine

83. Cluster Headache Treatment
Acute
Sumatriptan
6 mg SC – relief in 15 min
Intranasal spray sumatriptan or zolmitriptan – relief in 30 min
Triptans limits on daily usage
Limit to 2 SC or 3 nasal sprays per day to prevent tachyphylaxis or rebound
High flow O2 effective & safe [Cohen 2009]
O2 – L/min with loose fitting nonrebreathing facial mask for 15 min

84. Cluster Headache Treatment
Acute
DHE mg IM or IV useful as abortive agent
Octreotide (Sandostatin®) 100 mcg SC can abort an attack
NNT 5 for complete relief in 30 min
Prednisone mg – short course

85. Cluster Headache Treatment
Prophylactic
Verapamil mg/day

86. Daily Headache
When chronic daily headache is strictly unilateral, same side, consider diagnosis to be:
Hemicrania continua
Ipsilateral side one or more autonomic symptoms (ptosis, lacrimation, etc.)
Defined by absolute response to indomethacin (25 – 300 mg daily, must be continued indefinitely)
If intolerant of indomethacin conside COX2 inhibitor

87. Key Points Diagnosis of migraine headache is clinical
Almost always positive family history
Triptans are preferred treatment for frequent migraines
Discuss preventive therapy with all patients
Provide treatment plan for breakthrough pain

88. What Questions do you have?

89. References
Cohen AS et al. High-flow oxygen for treatment of cluster headache. JAMA 2009;302:
Colman I et al. Parenteral dexamethasone for acute severe migraine headache: meat-analysis of randomized controlled trials for preventing recurrence. BMJ 2008;336:
Friedman BW et al. The relative efficacy of meperidine for the treatment of acute migraine: a meta-analysis of randomized controlled trials. Ann Emerg Med 2008;52:
Friedman BW et al. A randomized controlled trial of prochlorperazine versus metoclopramide for treatment of acute migraine. Ann Emerg Med 2008;52:
Friedman BW et al. Treating headache recurrence after emergency department discharge: A randomized controlled trial of naproxen versus sumatriptan. Ann Emerg Med 2010;

90. References
Haghighi AB et al. Cutaneous application of menthol 10% solution as an abortive treatment of migraine without aura: a randomised, double-blind, placebo-controlled, crossed-over study. Int J Clin Pract 2010;64:
Kostic MA et al. A prospective, randomized trial of intravenous prochlorperazine versus subcutaneous sumatriptan in acute migraine therapy in the Emergency Department. Ann Emerg Med 2010;56:1-6.
Linde K et al. Acupuncture for migraine prophylaxis. Cochrane Database Syst Rev 2009;(1):CD001218
Schurks M et al. Migraine and cardiovascular disease: systematic review and meta-analysis. BMJ 2009;339:b3914.

91. References
Singh A et al. Does the addition of dexamethasone to standard therapy for acute migraine headache decrease the incidence of recurrent headache for patient treated in the emergency department. Acad Emerg Med 2008;15:
Spector JT et al. Migraine headache and ischemic stroke risk: an updated meta-analysis. Am J Med 2010;123: