Episode 201: Migraines

Show Notes

Initial Approach to Diagnosing Migraines:

• Differentiating between primary headaches (migraine, tension-type, cluster) and secondary causes (e.g., subarachnoid hemorrhage).
• The importance of patient history and reevaluation after initial treatment.
• Recognizing the unique presentation of cluster headaches and their management implications.

Effective Acute Migraine Treatments:

• First-line treatments including anti-dopaminergic medications like metoclopramide (Reglan) and prochlorperazine (Compazine), and parenteral NSAIDs like ketorolac (Toradol).
• The limited role of triptans in the ED due to side effects and less efficacy compared to anti-dopaminergics.
• The use of nerve blocks (greater occipital nerve block and sphenopalatine ganglion block) as effective treatments without systemic side effects.

Treatments to Avoid or Use with Caution:

• Diphenhydramine (Benadryl): Studies show it does not prevent akathisia from anti-dopaminergics nor improve migraine outcomes.
• IV Fluids: Routine use is not supported unless the patient shows signs of dehydration.
• Magnesium: Conflicting evidence with some studies showing no benefit or even harm.

Managing Refractory Migraines:

• Second-line treatments including additional doses of metoclopramide combined with NSAIDs or dihydroergotamine (DHE).
• Considering opioids as a last resort when other treatments fail.
• The potential use of newer medications like lasmiditan and CGRP antagonists.

Preventing Recurrence of Migraines:

• Administering a single dose of dexamethasone (4 mg IV) to reduce the risk of headache recurrence after discharge.
• Prescribing NSAIDs or triptans upon discharge for outpatient management.
• Recognizing and addressing chronic migraine, and initiating preventive therapies like propranolol when appropriate.

Key Takeaways

• Differentiate Primary from Secondary Headaches and Reassess After Treatment:
  • Use patient history and reevaluation post-treatment to distinguish migraines from more serious conditions, reducing unnecessary imaging and procedures.
• First-Line Treatments Are Effective:
  • Anti-dopaminergic medications and NSAIDs are the mainstay of acute migraine treatment in the ED.
  • Reserve opioids for cases unresponsive to multiple lines of treatment.
• Avoid Unnecessary Interventions:
  • Diphenhydramine and routine IV fluids do not have proven benefits and can be excluded to streamline care.
• Utilize Nerve Blocks for Refractory Cases:
  • Greater occipital nerve blocks and sphenopalatine ganglion blocks are effective alternatives for patients not responding to medication.
• Prevent Recurrence with Dexamethasone and Outpatient Planning:
  • A single IV dose of dexamethasone can help prevent recurrence.
  • Provide prescriptions and consider preventive therapies to reduce future ED visits.