Office-Based Migraine Management

Aka: Office-Based Migraine Management, Migraine Management Clinic Schedule

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II. Evaluation

  1. Migraine Treatment Optimization Questionnaire 4 (mTOQ-4)
    1. https://www.mdcalc.com/calc/10496/migraine-treatment-optimization-questionnaire-mtoq-4

III. Management: Office-Based Acute Migraine Management (adult dosing)

  1. See Acute Migraine Headache Medication
  2. See Migraine Headache Care in the Emergency Department
  3. Oral Analgesics (combined with other agents below)
    1. Acetaminophen
    2. NSAID (Ibuprofen orally or Ketorolac IV or IM)
  4. Antiemetics with Migraine-specific activity
    1. Metoclopramide 10 mg IM or very slowly IV, or oral
    2. Prochlorperazine IM or IV, or oral
  5. Acute Triptans (if not contraindicated, and early presentations)
    1. Sumatriptan SQ or Intranasal
    2. Rizatriptan MLT
  6. CGRP Antagonist
    1. Zavegepant (Zavzpret) nasal spray
  7. Consider adjunctive agents
    1. Dexamethason 10 mg oral, IM or IV
  8. Consider Nerve Block in Occipital Headache
    1. Greater Occipital Nerve Block
      1. May be combined with Supraorbital Nerve Block
  9. References
    1. (2026) Presc Lett 33(4): 7-8

IV. Management: Clinic Routine Follow-Up Schedule

  1. Visit 1 - Initial Evaluation
    1. Primary Goal
      1. Rule-out Organic Headache (Secondary Headache)
    2. Secondary Goals
      1. Eliminate Rebound Migraine habits (e.g. Analgesic use >10 days/month)
      2. Avoid Migraine Headache Triggers
      3. Patient Education Handouts regarding Headache
  2. Visit 2 - See 2-4 weeks after initial visit
    1. Primary Goal
      1. Establish Migraine Abortive Management
    2. Secondary Goals
      1. Review Migraine Headache Pathophysiology
      2. Review Headache Self-Help Measure
  3. Visit 3+ - See every 1-3 months until stable
    1. Primary Goal
      1. Consider Migraine Prophylaxis
    2. Secondary Goal
      1. Adjust Migraine Abortive Management
  4. Visit 4+ - See 2-4 times per year
    1. Primary Goal
      1. Turn Migraine Headache control over to patient
      2. Review Headache Self-Help Measure
    2. Secondary Goals
      1. Adjust Migraine Abortive Management
      2. Adjust Migraine Prophylaxis

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