1.08 Migraine Headache
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agk's Library of Common Simple Emergencies

Presentation
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The patient comes to the ED with a steady, 
severe, pain in the left or right side of the 
head, following ophthalmic or neurologic 
symptoms which resolved as the headache 
developed. Scintillating castellated scotomata 
in the visual field corresponding to the side 
of the subsequent headache are the classic 
aura, but transient weakness, vertigo, or 
ataxia are more likely to bring patients to the 
ED. Unlike other headaches, migraines are 
especially likely to awaken one in the morning. 
There may be a family or personal history of 
similar headaches as well.

What to do:
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- Migraine headaches (and similar recurrent 
   headache syndromes, with or without nausea 
   and vomiting) are usually aborted with 
   intravenous prochlorperazine (Compazine) 
   10mg or metoclopramide (Reglan) 10mg, with a 
   liter of saline.
- If the migraine is of recent onset, and the 
   patient has not already taken ergotamines, 
   and you want to avoid starting an 
   intravenous line, begin treatment with 
   sumatriptan (Imitrex) 6mg sc, or dihydro- 
   ergotamine (DHE 45) 1mg im (DHE can also be 
   given iv).
- If the pain has been present most of the day, 
   and has precipitated a secondary muscle 
   headache, evinced by scalp tenderness, add 
   ketorolac (Toradol) 60mg im or ibuprofen 
   (Motrin) 800mg po for non-steroidal anti- 
   inflammatory effect.
- If the pain remains severe, add narcotic 
   analgesics (meperidine, 50-l00mg im or iv) 
   and let the patient lie down in a dark, 
   quiet room. It can be cruel to attempt a 
   complete history and physical examination 
   (and unrealistic to expect the patient to 
   cooperate) before achieving some relief of 
   pain.
- After 20 minutes, when the patient is feeling 
   a little better, undertake the history and 
   physical examination. If there are persist- 
   ent changes in mental status or neurological 
   examination, a stiff neck, or fever, proceed 
   with computed tomography and/or lumbar 
   puncture to rule out intracranial hemorrhage 
   or infection as the actual cause of the 
   "migraine."
- If the presentation is indeed consistent with 
   a migraine, allow the patient to sleep in 
   the ED, undisturbed except for a brief 
   neurological examination each hour. 
   Typically the patient will awaken after a 
   few hours, with the headache completely 
   resolved or much improved, and no 
   neurological residua.
- For future attacks, if there are no cardio- 
   vascular risks, prescribe a self-injector 
   preloaded with 6mg of sumatriptan. If the 
   patient prefers to take medication orally, 
   try tablets of ergotamine 2mg and caffeine 
   l00mg (Cafergot), two at the first sign of 
   the aura, then one every half hour up to a 
   total day's dose of 6 tablets. If nausea and 
   vomiting prevent oral medication, Caffergot 
   is also available in rectal suppositories at 
   the same dosage, but one or two supposi- 
   tories are usually sufficient to relieve a 
   headache.
- Instruct the patient to return to the ED for 
   any change or worsening of the usual 
   migraine pattern, and make arrangements for 
   medical followup. First-time migraine 
   attacks deserve a thorough elective 
   neurological evaluation to establish the 
   diagnosis.

What not to do:
---------------
- Do not prescribe medications containing 
   egotamine, caffeine, or barbiturates for 
   continual prophylaxis. They will not be 
   effective this way, and withdrawal from 
   these drugs may produce headaches.
- Do not omit followup, especially for first 
   attacks.
- Do not miss meningitis, subarachnoid 
   hemorrhage, glaucoma or stroke, which may 
   deteriorate rapidly undiagnosed.

Discussion
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Even more characteristic of migraine than the 
aura is the unilateral pain ("migraine" is a 
corruption of "hemicranium"). The pathophysi- 
ology is probably unilateral cerebral vasospasm 
(producing the neurological symptoms of the 
aura) followed by vasodilation (producing the 
headache). Neurologic symptoms may persist into 
the headache phase, but the longer they 
persist, the less likely they are due to the 
migraine. Cluster headaches, probably also of 
vascular origin, are characterized by 
lacrimation, rhinorrhea, and clustering in 
time, but the treatment of an attack is usually 
the same as for migraines. 

Acute migraine headaches are self-limited and 
respond well to placebos, so many therapies are 
effective. Medications for acute migraine pass 
in and out of style, and the above represent 
popular regimens at the time of writing. 
Ergotamines, phenothiazines and serotinin 
inhibitors may all work by cerebral 
vasoconstriction. 

One should be cautious in the use of ergot or 
serotonin agonists in any patient who has 
angina or focal weakness or sensory deficits. 
It is possible to precipitate an ischemic 
infarct of the brain or heart in such patients 
by using preparations which act by causing 
vasoconstriction. 

Patients with aneurysms or A-V malformations 
can present clinically as migraine patients. If 
there is something different about the severity 
or nature of this headache, one must think of 
the possibility of a subarachnoid hemorrhage. 
Headaches that are always on the same side and 
in the same location are very suspicious for an 
underlying structural lesion (e.g., aneurysm, 
AV malformation). 

Many patients seeking narcotics have learned 
that faking a migraine headache is even easier 
than faking a ureteral stone, but they usually 
do not follow through the typical course of 
falling asleep after a shot and waking up a few 
hours later with pain relieved. It is a good 
policy to limit narcotics to one or two shots 
for migraine headaches, and not prescribe oral 
narcotics from the ED.

References:
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- Klapper JA, Stanton J: Current emergency 
   treatment of severe migraine headaches. 
   *Headache* 1993;33:560-562.
- Salomone JA, Thomas RW, Althoff JR et al: An 
   evaluation of the role of the ED in the 
   management ot migraine headaches. *Am J 
   Emerg Med* 1994;12:134-137

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