20. Migraine

• Limit stimuli (i.e., light, loud noises) and activity.

• Start abortive treatment as soon as possible. [19]

• Treat nausea and vomiting, if present.

  • IV fluids

  • Parenteral antiemetics: e.g., metoclopramide, prochlorperazine

• First-line treatment consists of NSAIDs, acetaminophen, acetylsalicylic acid, or combinations including caffeine.

  • If tolerating PO, consider one of the following:

    • Ibuprofen

    • Aspirin

    • Acetaminophen

    • Acetaminophen/aspirin/caffeine

  • If nausea/vomiting are present, consider one of the following:

    • Ketorolac

    • Diclofenac

• Second-line: Treat as “Moderate to severe headache.”

• Children: ibuprofen and family counseling

Trial a parenteral antidopaminergic agent OR start a migraine-specific agent.

• Parenteral antidopaminergics

  • Metoclopramide

  • Prochlorperazine PLUS diphenhydramine [15][20]

• Migraine-specific agents: triptans (e.g., sumatriptan) OR ergotamine; do not combine these agents! [21]

  • First-line: oral or parenteral triptans

    • If tolerating PO, consider one of the following:

      • Sumatriptan-naproxen

      • Zolmitriptan

    • If nausea/vomiting are present or there is a higher analgesic requirement, consider one of the following:

      • Sumatriptan

      • Zolmitriptan

  • Second-line: consider a parenteral ergotamine (e.g., dihydroergotamine)

• Short-term recurrence prevention: Consider IV dexamethasone. [22]

• Refractory headache: See “Status migrainosus.”

• 5-HT1B/1D receptor agonists that cause:

  • Vasoconstriction of (dilated) cranial and basilar arteries

  • Inhibition of trigeminal nerve nociception

  • Inhibition of vasoactive peptide secretion

• Most effective if taken at the onset of headache

• Migraine headaches

• Cluster headaches

• Vasospasm of coronary vessels → coronary ischemia (rare)

• Paresthesia and sensation of cold in the extremities

• Serotonin syndrome (if taken with other 5-HT agonists)

• Temporary blood pressure increase (very common)

• Dizziness, malaise, flashes

• Frequent intake (≥ 10 x/month) can lead to headaches.

• Hypertension

• Coronary artery disease

• Vasospastic angina

• Peripheral artery disease

• Hypertension

• Vasoconstriction by binding to 5-HT1B/1D serotonin receptors and alpha-adrenergic receptors [23]

• Vascular headaches (i.e., migraine and variants, histaminic cephalalgia)

• ECG changes

• Ischemia

• Nausea/vomiting

• Numbness, paresthesia, myalgia, weakness

• Ergot toxicity

  • An intoxication that causes convulsive (e.g., fasciculations, paresthesias, and seizures) and/or gangrenous symptoms (e.g., peripheral necrosis)

  • Historically, it occurred from consumption of ergot alkaloids produced by fungi (e.g., contaminated rye).

  • Nowadays, it is only rarely seen due to overdosing or pharmacological interactions with ergot-derived drugs (e.g., ergotamine).

• Pregnancy

• Peripheral vascular disease

• Coronary artery disease

• Hypertension

• Pharmacologic interactions