II. Evaluation: Direct Headache Management per Headache severity

  1. Migraine Disability Assessment Scale (MIDAS)
    1. http://www.midas-migraine.net/US/question/

III. Management: General Measures

  1. See Headache Self-Help Measures (e.g. Quiet dark room)
  2. Eliminate Rebound Migraine Factors
  3. Avoid Opioid agents
  4. See Migraine Headache Management in Children
  5. See Headache in Pregnancy

IV. Management: Aura or mild to moderate early Migraine (<2 hours)

  1. Advance Analgesics hourly
    1. Ibuprofen
    2. Naproxen (Naprosyn, Anaprox DS)
    3. Diclofenac
    4. Indomethacin
  3. Combination agents (do not use Aspirin in children, increased GI irritation with Aspirin)
    1. Excedrin Migraine (Aspirin, Acetaminophen, Caffeine)
    2. Aspirin 1000 mg with Metoclopramide (see below)
      1. Tfelt-Hansen (1995) Lancet 346:923-6 [PubMed]
  4. Alternatives for NSAID intolerant patients
    1. Acetaminophen 1000 mg
    2. COX2 Inhibitors

V. Management: Moderate Migraine Headache (<2 to 4 hours) refractory to above

  1. Consider administering at 1 hour for failed improvement with initial meds listed above
  2. Abortive Medications (in combination with Anti-emetic, see below)
    1. First-Line
      1. Triptan agents (first-line, see below)
      2. Consider coadministration with NSAIDs (Indomethacin is available as a suppository)
    2. Other agents
      1. Intranasal Dihydroergotamine or DHE (Triptans are preferred, see below)
      2. Isometheptene (e.g. Midrin which also contains Acetaminophen and dichloralphenazone) may be effective
        1. However, Midrin is a controlled substance (schedule IV) due to the Sedative dichloralphenazone
        2. Generally avoided and largely replaced by Serotonin Agonists (esp. Triptans)
      3. Avoid Opioids
      4. Avoid Butalbital (e.g. Fiorinal)
        1. Barbiturate with poor efficacy
        2. Potentially addictive with risk of withdrawal
  3. Antiemetic
    1. First-line (dopamine Antagonists, warn patients regarding Extrapyramidal Side Effects)
      1. Metoclopramide (Reglan, enhances abortive medication absorption)
      2. Prochlorperazine (Compazine)
    2. Other Anti-emetics (some available as suppositories)
      1. Dramamine
      2. Atarax
      3. Phenergan

VI. Management: Severe Migraine Headache (2-6 hours) refractory to above

  1. See Emergency Department Migraine Headache Care
  2. Antiemetic as above
  3. Serotonin Agonist
    1. Triptans (first-line, preferred)
      1. Sumatriptan (Imitrex) - subcutaneous form is more effective than oral, intranasal
      2. Rizatriptan (Maxalt MLT) - orally disintegrating tablets
      3. Zolmitriptan (Zomig) - orally disintegrating tablets
      4. Almotriptan (Axert)
      5. Eletriptan (Relpax)
    2. Triptans (longer acting agents for recurrent Migraines)
      1. Naratriptan (Amerge, generic)
      2. Frovatriptan (Frova)
    3. Dihydroergotamine or DHE (e.g. Migranal Nasal Spray, second-line)
      1. Do not use within 24 hours of a Triptan
      2. Nausea is common, and reduce dose if Leg Cramps or Paresthesias may occur

VII. Management: Severe Refractory Migraine Headache (6 to 72 hours)

VIII. Management: Vasocontrictor Contraindications

  1. Patients in whom Vasoconstrictors (e.g. Triptan, DHE) are contraindicated
    1. Coronary Artery Disease
    2. Hemiplegic Migraines
    3. Basilar Migraines
  2. Alternative agents
    1. Excedrin Migraine (Acetaminophen, Aspirin, Caffeine)
    2. NSAIDS
    3. Dopamine Antagonists (e.g. Metoclopramide or Prochlorperazine)

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