Migraine Headache Management

Aka: Migraine Headache Management, Migraine Management

1. See Also
   1. Migraine Headache
   2. Migraine Headache Management in Children
   3. Migraine Management Clinic Schedule
   4. Migraine Abortive Management
   5. Migraine Prophylaxis
   6. Migraine Headache Care in the Emergency Department
   7. Migraine Medications in Pregnancy
   8. Migraine Medications in Breast Feeding
   9. Headache in Pregnancy
2. Evaluation: Direct Headache Management per Headache severity
   1. MigraineDisability Assessment Scale (MIDAS)
      1. http://www.midas-migraine.net/US/question/
3. Management: General Measures
   1. See Headache Self-Help Measures (e.g. Quiet dark room)
   2. Eliminate Rebound Migraine Factors
   3. Avoid Narcotic agents
4. 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
   3. Other Analgesics (NSAIDS)
      1. Anaprox DS
      2. Indomethacin
   4. Alternatives for NSAID intolerant patients
      1. Acetaminophen 1000 mg
      2. COX2 Inhibitors
      3. Ultram
5. 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
6. Management: Severe Migraine Headache (2-6 hours) refractory to above
   1. Antiemetic as above
   2. Serotonin Agonist
      1. Dihydroergotamine (e.g. Migranal Nasal Spray)
      2. Triptans
         1. Sumatriptan (Imitrex)
         2. Rizatriptan (Maxalt)
         3. Zolmitriptan (Zomig)
         4. Naratriptan (Amerge)
7. Management: Severe Refractory Migraine Headache (6 to 72 hours)
   1. See Emergency Department Migraine Headache Care
8. References
   1. Jackson (1998) CMEA Internal Medicine Lecture,San Diego
   2. Moore (1997) Am Fam Physician 56(8):2039-48
   3. Noble (1997) Am Fam Physician 56(9):2279-86
   4. Polizzotto (2002) J Fam Pract 51(2):161-7
   5. Silberstein (2004) Lancet 363:381-91