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 Narcotic agents

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

  1. Advance Analgesics hourly
  2. First-line Analgesics
    1. Excedrin Migraine (Aspirin, Acetaminophen, Caffeine)
    2. Aspirin with metoclopramide (see below)
      1. Tfelt-Hansen (1995) Lancet 346:923-6 [PubMed]
  3. Other Analgesics (NSAIDS)
    1. Anaprox DS
    2. Indomethacin
  4. Alternatives for NSAID intolerant patients
    1. Acetaminophen 1000 mg
    2. COX2 Inhibitors
    3. Ultram

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. Antiemetic
    1. First-line
      1. Reglan (enhances abortive medication absorption)
      2. Prochlorperazine (Compazine)
    2. Other Anti-emetics (some available as suppositories)
      1. Dramamine
      2. Atarax
      3. Phenergan
  3. Abortive Medications (in combination with Anti-emetic)
    1. Triptan agents (see below)
    2. Indomethacin suppository
    3. Isometheptene (e.g. Midrin) may be effective
    4. Butalbital (e.g. Fiorinal) not recommended
      1. Barbiturate with poor efficacy
      2. Potentially addictive wwith risk of withdrawal

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

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

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