MigraineMANAGEMENT

NEUROLOGICAL PRESENTATIONS · 12 SECTIONS

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643 items

☷ Legend

01Approach to the Critical Patient/attcp62

Triage and immediate safety

›Immediate priorities

›Airway risk

›If decreased consciousness, airway protection pathway

›Breathing risk

›Hypoxia

›Circulatory risk

›Hypotension

›Pain and vomiting control

›If persistent emesis, IV route preference

›Isolation considerations

›Fever with meningismus

Secondary headache exclusion

›High-risk features

›Thunderclap onset

›Peak intensity within 1 minute

›New focal neurologic deficit

›Persistent deficit between attacks

›Altered mental status

›New confusion

›Fever or meningismus

›Neck stiffness

›Papilledema

›Visual obscurations

›Pregnancy or postpartum

›Preeclampsia spectrum concern

›Immunocompromise

›HIV with low CD4

›Anticoagulation or bleeding diathesis

›Warfarin or DOAC use

›Cancer history

›Known metastatic disease

›Head trauma

›Recent fall or impact

›Age over 50 with new headache

›Giant cell arteritis concern

›Pattern change

›Progressively worsening frequency

›Exertional or sexual trigger

›Sentinel hemorrhage concern

ED pathway selection

›Working pathway

›Migraine-likely

›Typical phenotype

›Normal neurologic exam

›No high-risk features

›Secondary-headache workup

›Any high-risk feature present

›Abnormal neurologic exam

›First or worst headache

›Mixed

›Migraine phenotype with new red flag

Key concepts

›Migraine core concepts

›Recurrent episodic headache disorder

›Moderate to severe pain

›Associated features

›Nausea or vomiting

›Photophobia

›Phonophobia

›Disability focus

›Functional impairment

›ED goal

›Rapid symptom relief

›Exclusion of secondary causes when indicated

›Recurrence prevention strategy

02History/hx108

Phenotype and diagnostic alignment

›Headache phenotype

›Location

›Unilateral

›Bilateral

›Quality

›Pulsating

›Pressure-like

›Intensity

›Mild

›Moderate

›Severe

›Duration

›Less than 4 hours

›4 to 72 hours

›More than 72 hours

›Aggravation

›Routine physical activity worsens pain

›Associated symptoms

›Nausea

›Vomiting

›Photophobia

›Phonophobia

›Osmophobia

Aura and neurologic symptoms

›Aura features

›Visual

›Scintillations

›Zigzag lines

›Scotoma

›Sensory

›Unilateral tingling

›Speech or language

›Transient aphasia

›Time course

›Gradual spread over at least 5 minutes

›Each symptom 5 to 60 minutes

›Atypical aura flags

›Motor weakness

›Brainstem symptoms

›First aura after age 40 to 50

Timing and trajectory

›Temporal pattern

›Onset

›Sudden

›Gradual

›Peak

›Immediate peak

›Progressive peak

›Course

›Episodic

›Daily

›Progressive

›Prior similar episodes

›Same quality as usual migraine

›Different from usual migraine

Triggers and exposures

›Trigger inventory

›Sleep disruption

›Sleep deprivation

›Stress

›Acute stress

›Hormonal

›Menses association

›Dietary

›Alcohol

›Skipped meals

›Environmental

›Bright light

›Strong smells

›Medication related

›Recent analgesic escalation

Red flag history

›Secondary headache risk history

›Pregnancy or postpartum

›Hypertension symptoms

›Hypercoagulable risk

›OCP use

›Recent infection

›Vascular risk

›Known aneurysm

›Infectious risk

›Recent sinusitis

›Immunosuppression

›Steroid therapy

›Malignancy

›New cancer diagnosis

Medication history and medication-overuse risk

›Acute medication use

›NSAIDs days per month

›15 or more days

›Triptans days per month

›10 or more days

›Opioids days per month

›10 or more days

›Combination analgesics days per month

›10 or more days

›Preventive therapy history

›Current preventive agents

›Topiramate

›Propranolol

›Amitriptyline

›CGRP pathway agents

›Adherence and adverse effects

›Missed doses

Prior workup and response

›Prior ED visits

›Response to dopamine antagonists

›Metoclopramide benefit

›Response to NSAIDs

›Ketorolac benefit

›Steroid use

›Dexamethasone given

›Opioid exposure

›Prior opioid benefit or harm

03Physical Exam/exam57

Vital signs and general exam

›Physiologic status

›Blood pressure

›Severe hypertension

›Temperature

›Fever

›Heart rate

›Tachycardia

›Oxygen saturation

›Hypoxia

›General appearance

›Toxic appearance

›Concern for infection

›Photophobia behavior

›Prefers dark room

Neurologic exam

›Neurologic screen

›Mental status

›Orientation

›Cranial nerves

›Visual fields

›Extraocular movements

›Motor

›Focal weakness

›Sensory

›Hemisensory loss

›Coordination

›Ataxia

›Gait

›Unable to ambulate

›Meningeal signs

›Neck stiffness

›Pain with flexion

Funduscopic and ocular findings

›Ocular exam

›Pupillary size and reactivity

›Anisocoria

›Fundus

›Papilledema

›Visual acuity

›Acute loss

Head and neck

›Local pathology

›Sinus tenderness

›Fever plus sinus pain

›Temporal artery region

›Scalp tenderness

›TMJ and jaw

›Jaw claudication

›Cervical exam

›Occipital tenderness

›Occipital neuralgia phenotype

PITFALLS

›High-risk pitfalls

›Normal exam with thunderclap headache

›SAH still possible

›First migraine-like headache in older adult

›Secondary headache more likely

›Persistent neurologic symptoms

›Stroke mimic risk

›Papilledema missed without fundus assessment

›Intracranial hypertension risk

04Differential Diagnosis/ddx46

Life-threatening secondary headache

›Dangerous causes

›Subarachnoid hemorrhage (ICD-10 I60)

›Thunderclap onset

›Intracerebral hemorrhage (ICD-10 I61)

›Focal deficit

›Ischemic stroke or TIA (ICD-10 I63 or G45)

›Persistent deficit

›Meningitis or encephalitis (ICD-10 G00 to G04)

›Fever

›Cerebral venous sinus thrombosis (ICD-10 I67.6)

›Pregnancy

›OCP use

›Cervical artery dissection (ICD-10 I77.74)

›Neck pain

›Horner syndrome

›Hypertensive emergency (ICD-10 I16.1)

›End-organ symptoms

›Acute glaucoma (ICD-10 H40.21)

›Red painful eye

›Giant cell arteritis (ICD-10 M31.6)

›Age over 50

›Jaw claudication

›Pituitary apoplexy (ICD-10 E23.6)

›Acute headache plus visual symptoms

›Carbon monoxide toxicity (ICD-10 T58)

›Multiple household members symptomatic

Migraine and primary headache mimics

›Primary headache mimics

›Tension-type headache (ICD-10 G44.2)

›Bilateral pressure

›Cluster headache (ICD-10 G44.0)

›Autonomic features

›Trigeminal neuralgia (ICD-10 G50.0)

›Electric shock facial pain

›Medication-overuse headache (ICD-10 G44.40)

›Frequent acute medication days

›Idiopathic intracranial hypertension (ICD-10 G93.2)

›Papilledema

›Pulsatile tinnitus

SNOMED CT alignment

›Standardized terms

›Migraine disorder

›Migraine without aura

›Migraine with aura

›Status migrainosus

›Prolonged migraine attack

›Medication overuse headache

›Analgesic overuse headache

05Laboratory Tests/lt33

Baseline labs when indicated

›Targeted laboratory selection

›Pregnancy test

›All patients with pregnancy potential before teratogenic therapies

›Serum glucose

›Altered mental status

›Electrolytes and creatinine

›Significant vomiting

›Dehydration concern

›Complete blood count

›Fever

›Immunocompromise

›CRP and ESR

›Age over 50 with new headache

›Temporal tenderness

›Liver enzymes

›Planned valproate use

Secondary headache directed labs

›Condition-specific labs

›Blood cultures

›Sepsis concern

›Lactate

›Shock concern

›Coagulation profile

›Anticoagulant use

›Liver disease

›Urinalysis and urine protein

›Pregnancy with hypertension concern

PITFALLS and limitations

›Lab limitations

›Normal CBC in early meningitis

›CSF decision based on clinical risk

›ESR and CRP may be normal in some giant cell arteritis

›High clinical suspicion still warrants urgent specialty pathway

›Electrolytes may lag behind clinical dehydration

›Volume status based on exam

06Diagnostic Tests/dt68

Scoring Systems

›Decision tools and criteria

›Migraine diagnostic features

›Recurrent attacks

›4 to 72 hour duration

›Unilateral or pulsating pain

›Moderate to severe intensity

›Activity aggravation

›Nausea or vomiting

›Photophobia or phonophobia

›Secondary headache red flags

›Sudden onset

›Neurologic deficit

›Immunosuppression

›Age over 50

›Pregnancy or postpartum

›Papilledema

›Ottawa subarachnoid hemorrhage rule use case

›Acute nontraumatic headache with peak within 1 hour

›Exclusion when new neurologic deficit present

›Disability screening options

›HIT-6

›MIDAS

MRI

›MRI indications

›Posterior fossa concern

›Ataxia

›Demyelination concern

›Multifocal neurologic symptoms

›Tumor concern

›Progressive headache pattern

›Cerebral venous sinus thrombosis concern

›MRV pathway

›MRI limitations

›Time and availability constraints

›Unstable patients unsuitable

›Motion artifact with severe pain

›Analgesia and antiemetic needed

›CT head noncontrast

›Indications

›Thunderclap headache

›New focal neurologic deficit

›Altered mental status

›Head trauma

›Immunocompromised with fever

›Anticoagulation with severe headache

›Interpretation targets

›Subarachnoid blood

›Intracerebral hemorrhage

›Mass effect

›Hydrocephalus

›CT angiography head and neck

›Indications

›Suspected aneurysmal SAH pathway

›Suspected cervical artery dissection

›Pitfalls

›Incidental aneurysm

›Radiation and contrast exposure

Ultrasound

›Point-of-care ultrasound applications

›Optic nerve sheath diameter

›Intracranial hypertension surrogate

›Ocular assessment

›Retinal detachment mimic

›Temporal artery ultrasound

›Giant cell arteritis supportive findings

›Ultrasound limitations

›Operator dependence

›Training variability

›Does not replace definitive neuroimaging when indicated

›Red flag pathway still required

07Disposition/dispo36

ED discharge criteria

›Safe discharge profile

›Symptom improvement

›Pain controlled to functional level

›Normal neurologic exam

›No persistent focal deficit

›Secondary headache excluded when indicated

›Imaging or LP pathway completed if needed

›Oral intake adequate

›Tolerating fluids

›Discharge plan

›Acute rescue regimen provided

›Follow-up arranged

Admission and observation criteria

›Higher level of care triggers

›Status migrainosus

›Persistent severe symptoms over 72 hours

›Refractory migraine

›Failure of multiple ED regimens

›Intractable vomiting

›Dehydration requiring IV therapy

›Diagnostic uncertainty

›Unresolved red flag concern

›Complications

›Seizure

›Persistent neurologic deficit

Transfer and consultation triggers

›Specialty triggers

›Neurology consult

›New neurologic deficit

›Hemiplegic migraine concern

›Refractory status migrainosus

›Neurosurgery consult

›SAH or mass lesion on imaging

›Obstetrics consult

›Pregnancy with headache plus hypertension

›Ophthalmology consult

›Acute glaucoma concern

›Vision loss

08Treatment/t100

Nonpharmacologic and environment

›Supportive measures

›Dark quiet room

›Light sensitivity reduction

›Hydration strategy

›IV fluids for dehydration

›Trigger removal

›Screen brightness reduction

First-line ED regimen

›Standard abortive regimen

›Dopamine antagonist antiemetic

›Metoclopramide IV 10 mg

›Repeat dose once after 30 to 60 minutes if partial response

›Akathisia monitoring

›Prochlorperazine IV 10 mg

›Hypotension monitoring

›Akathisia monitoring

›NSAID

›Ketorolac IV 15 mg

›Alternative IV 30 mg in selected adults without risk factors

›Renal impairment avoidance

›Ibuprofen PO 400 to 800 mg

›If oral route tolerated

›Antihistamine adjunct

›Diphenhydramine IV 25 mg

›Akathisia prevention with dopamine antagonists

›Sedation counseling

›Recurrence prevention

›Dexamethasone IV 10 mg

›Alternative IV 24 mg based on local protocol

›Single dose only

Second-line and phenotype-directed options

›Triptan pathway

›Sumatriptan SC 6 mg

›Repeat once after 1 hour if needed

›Maximum 12 mg in 24 hours

›Avoid with ischemic heart disease

›Sumatriptan intranasal 20 mg

›Alternative when IV access not desired

›Dihydroergotamine pathway

›Dihydroergotamine IV 0.5 to 1 mg

›Premedication with antiemetic

›Metoclopramide IV 10 mg

›Repeat every 8 hours in monitored setting if needed

›Avoid in pregnancy

›Avoid within 24 hours of triptan

›Magnesium pathway

›Magnesium sulfate IV 1 to 2 g over 20 to 30 minutes

›Preferred with aura phenotype

›Hypotension monitoring

›Valproate pathway

›Valproate IV 500 to 1000 mg

›Avoid in pregnancy

›Hepatic disease caution

›Acetaminophen pathway

›Acetaminophen PO 1000 mg

›Alternative IV 1000 mg

›Max daily dose adjustment for liver disease

Refractory migraine and status migrainosus

›Escalation strategies

›Chlorpromazine IV 12.5 to 25 mg

›Slow infusion

›Hypotension monitoring

›QT prolongation risk

›ECG if risk factors

›Ketamine low-dose infusion pathway

›If severe refractory pain and monitored setting available

›Psychoperceptual effects counseling

›Occipital nerve block

›Local anesthetic options

›Lidocaine 1 percent 2 to 3 mL per side

›Bupivacaine 0.25 percent 2 to 3 mL per side

›Contraindications

›Local infection

›Anticoagulation with high bleeding risk

›Inpatient regimen consideration

›Repeated DHE protocol in observation or admission

Avoidance and safety

›High-risk therapy avoidance

›Opioids

›Higher recurrence risk

›Medication-overuse risk

›Butalbital combinations

›Dependence risk

›Medication-overuse risk

›Contraindications and interactions

›Triptans

›Uncontrolled hypertension

›Hemiplegic migraine concern pending specialist pathway

›Ergot derivatives

›Pregnancy

›Peripheral vascular disease

›NSAIDs

›Chronic kidney disease

›GI bleeding risk

Preventive planning and follow-up treatment

›Outpatient transition

›Acute rescue plan

›NSAID first at home

›Triptan early in attack when appropriate

›Preventive therapy referral criteria

›4 or more migraine days per month

›Significant disability

›Medication-overuse counseling

›Limit triptan days under 10 per month

›Limit NSAID days under 15 per month

09Special Populations/sp47

Pregnancy

›Pregnancy considerations

›Secondary headache expansion

›Preeclampsia spectrum

›Headache plus hypertension

›Cerebral venous sinus thrombosis

›Postpartum risk

›Medication safety

›Preferred agents

›Acetaminophen

›Metoclopramide

›Avoid agents

›Valproate

›Ergot derivatives

›NSAIDs in third trimester

›Imaging approach

›MRI without gadolinium when feasible

›Red flag pathway

Geriatric

›Older adult considerations

›Higher secondary headache probability

›New headache after age 50

›Giant cell arteritis pathway

›ESR and CRP screening

›Temporal tenderness and jaw claudication

›Medication cautions

›Dopamine antagonist hypotension risk

›Slow administration

›NSAID renal and GI risk

›Lower dose preference

›Triptan cardiovascular contraindications

›CAD screening history

Pediatrics

›Pediatric considerations

›Weight-based dosing

›Metoclopramide IV 0.1 to 0.2 mg per kg

›Maximum 10 mg

›Ketorolac IV 0.5 mg per kg

›Maximum 15 mg

›Prochlorperazine IV 0.15 mg per kg

›Maximum 10 mg

›Secondary headache red flags

›Morning headache with vomiting

›Intracranial mass concern

›Abnormal neurologic exam

›Imaging pathway

›Hydration emphasis

›Dehydration common trigger

›Triptan options

›Sumatriptan intranasal per local age guidance

10Background/b33

Epidemiology

›Epidemiology summary

›High population prevalence

›Common cause of ED headache visits

›Sex distribution

›Higher prevalence in females after puberty

›Peak age

›Young to middle adulthood

›Disability burden

›Leading cause of years lived with disability in young adults

Pathophysiology

›Pathophysiology overview

›Trigeminovascular activation

›Meningeal nociceptor sensitization

›Central sensitization

›Cutaneous allodynia phenotype

›Neurotransmitters and peptides

›CGRP involvement

›Serotonin pathway involvement

›Aura mechanism

›Cortical spreading depolarization model

Therapeutic Considerations

›Treatment rationale

›Dopamine antagonists

›Antiemetic plus analgesic benefit

›NSAIDs

›Peripheral inflammation modulation

›Triptans

›Serotonin receptor agonism

›Steroid single dose

›Reduced early recurrence after ED discharge

›Medication-overuse prevention

›Overuse perpetuates chronic headache cycle

›Opioid avoidance rationale

›Poor migraine-specific efficacy

›Higher relapse and return visits

11Patient Discharge Instructions/pdi30

copy discharge instructions

›Discharge packet

›Diagnosis

›Migraine headache

›Home treatment plan

›Hydration

›Rest in dark quiet room

›Early use of prescribed rescue medication

›Medication limits

›Triptans under 10 days per month

›NSAIDs under 15 days per month

›Avoid opioids for migraine when possible

›Follow-up

›Primary care or neurology within 1 to 2 weeks if recurrent

›Headache diary

›Frequency

›Triggers

›Medications used

›Return to ED now

›Sudden severe headache reaching peak within 1 minute

›New weakness

›New trouble speaking

›New confusion

›Fainting

›Fever

›Neck stiffness

›New vision loss

›Persistent vomiting with inability to keep fluids down

›Headache after head injury

›Headache in pregnancy with high blood pressure symptoms

›Worst headache of life

12References/r23

Clinical guidelines and evidence sources

›Core references

›International Classification of Headache Disorders third edition

›Migraine diagnostic criteria framework

›Emergency headache clinical policy sources

›Imaging and secondary headache evaluation standards

›Acute migraine in emergency care evidence syntheses

›Dopamine antagonist efficacy

›NSAID efficacy

›Dexamethasone recurrence reduction

›Medication-overuse headache consensus statements

›Monthly day thresholds for overuse

Landmark trials and comparative effectiveness

›Evidence base

›Dopamine antagonist randomized trials

›Metoclopramide outcomes

›Prochlorperazine outcomes

›NSAID trials

›Ketorolac outcomes

›Steroid adjunct trials

›Single-dose dexamethasone relapse reduction

›Triptan trials

›Subcutaneous sumatriptan rapid relief

›DHE protocols

›Status migrainosus regimen evidence

Evidence & Review

Reviewed by SymptomDx Medical Team · Last reviewed June 16, 2026

SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.