Hormonal fluctuations — perimenstrual attacks common
Alcohol — especially red wine
Caffeine excess or withdrawal
Attack frequency and disability
Number of headache days per month
Number of days with functional impairment
Episodic less than 15 days per month vs chronic 15 or more days per month
Migraine Disability Assessment (MIDAS) score for grading
Past medical and medication history
Prior headache history
Age of onset
Prior ED visits and treatments received
Previous diagnostic workup including neuroimaging
Medication overuse history
Triptan use more than 10 days per month
NSAID or acetaminophen use more than 15 days per month
Opioid or barbiturate use frequency
Contraindications to therapy
Cardiovascular disease — CAD, stroke, PVD limiting triptan use
Pregnancy status — major treatment implications
Renal or hepatic disease affecting NSAID or medication dosing
Seizure disorder — topiramate or valproate dual benefit consideration
Family history
First-degree relatives with migraine — 2 to 4 times increased risk
Familial hemiplegic migraine
Psychiatric comorbidities — depression, anxiety, bipolar disorder in family
Physical Exam
Vital signs
Hemodynamic snapshot
Blood pressure — hypertension may indicate secondary cause
Heart rate — tachycardia with severe pain or dehydration
Temperature — fever indicates secondary headache until proven otherwise
Respiratory rate and oxygen saturation
Neurological exam
Mental status
Level of consciousness and orientation
Attention and cognitive speed assessment
Speech fluency and comprehension
Cranial nerves
Pupillary size and reactivity — anisocoria as red flag
Fundoscopy for papilledema
Extraocular movements — third nerve palsy from posterior communicating artery aneurysm
Visual fields
Motor and coordination
Pronator drift
Finger-nose-finger and rapid alternating movements
Gait if able
Sensory
Focal hemisensory deficit distinguishing aura from fixed deficit
Reflexes
Hyperreflexia in preeclampsia
Clonus for severe preeclampsia
Meningeal and vascular exam
Meningeal signs
Nuchal rigidity — neck flexion resistance
Kernig sign — inability to extend knee with hip flexed 90 degrees
Brudzinski sign — hip and knee flexion on neck flexion
Jolt accentuation — headache worsening with horizontal head rotation at 2 to 3 Hz, sensitivity 97% for meningitis
Vascular exam
Temporal artery tenderness and decreased pulsation — giant cell arteritis in those over 50
Carotid bruit — carotid dissection consideration
Scalp tenderness distribution
PITFALLS
Diagnostic pitfalls
Assuming prior headache diagnosis without reassessment of current attack characteristics
Missing meningismus in elderly or immunocompromised patients — subtle presentation
Equating nausea and photosensitivity exclusively to migraine — present in SAH
Third nerve palsy as triptan effect rather than posterior communicating artery aneurysm
Failing to examine fundus for papilledema in refractory or atypical headache
Differential Diagnosis
Life-threatening causes
Subarachnoid hemorrhage
ICD-10 I60.9
Thunderclap onset — worst headache of life
Meningismus, photophobia, nausea overlapping with migraine
CT sensitivity 98% within 6 hours; LP required if CT negative
Cerebral venous sinus thrombosis
ICD-10 G08
Progressive headache with papilledema and focal deficits
Pregnancy and postpartum highest risk period
Diagnosis by MR venography or CT venography
Meningitis or encephalitis
ICD-10 G03.9 meningitis, G04.90 encephalitis
Fever, nuchal rigidity, altered mental status
Photophobia and phonophobia overlap with migraine — LP required
Posterior communicating artery aneurysm
Third nerve palsy with ptosis, mydriasis, ophthalmoplegia
May present as sentinel headache before rupture
Hypertensive encephalopathy or PRES
Severe hypertension with encephalopathy and headache
ICD-10 I67.4
Serious secondary headaches
Giant cell arteritis
ICD-10 M31.6
Age over 50 — new temporal headache with jaw claudication
ESR greater than 50 mm/hr and elevated CRP
Vision loss risk without treatment
Idiopathic intracranial hypertension
ICD-10 G93.2
Young obese women — daily headache with papilledema and pulsatile tinnitus
Visual obscurations and sixth nerve palsy
Intracranial mass lesion
Headache worse in morning and with Valsalva
Progressive pattern over weeks
Papilledema and focal deficits
Common mimics
Tension-type headache
ICD-10 G44.2
Bilateral pressing or tightening quality
Mild to moderate severity — not worsened by activity
No nausea or vomiting
Cluster headache
ICD-10 G44.0
Strictly unilateral periorbital location
Duration 15 to 180 minutes
Ipsilateral autonomic features — lacrimation, rhinorrhea, ptosis, miosis
Medication overuse headache
ICD-10 G44.40
15 or more headache days per month with acute medication use for over 3 months
Headache present on waking, improves with analgesics temporarily
Cervicogenic headache
Occipital to frontal radiation
Neck movement provokes or worsens headache
Tenderness at C2 to C3 facets
Acute angle-closure glaucoma
ICD-10 H40.2
Periorbital pain with eye injection, blurred vision, and halos
Tonometry diagnostic
Laboratory Tests
Core acute assessment
Complete blood count
Leukocytosis — infection or inflammatory cause
Thrombocytopenia — thrombotic thrombocytopenic purpura or HELLP
Anaemia — contributory or systemic disease
Metabolic panel
Serum sodium — hyponatraemia as headache cause
Renal function — NSAID safety and medication dosing
Glucose — hypoglycaemia trigger or hyperglycaemia
Inflammatory markers
ESR and CRP — giant cell arteritis if age over 50
ESR typically greater than 50 mm/hr in GCA
CRP sensitivity 97.5% for GCA
Procalcitonin if meningitis or systemic infection suspected
Targeted investigations
Pregnancy test
Urine or serum beta-hCG in all women of reproductive age
Positive result changes all treatment decisions
Coagulation studies
PT, aPTT for thrombosis or coagulopathy concern
D-dimer if cerebral venous thrombosis or PE suspected
Toxicology
Serum acetaminophen and salicylate levels if medication overuse suspected
Drug screen if altered mental status present
Lumbar puncture
Indications — thunderclap headache with negative CT
Opening pressure in mmH2O — elevated in IIH or venous thrombosis
RBC count and xanthochromia — SAH
Cell count, protein, glucose, and culture — meningitis
Timing — xanthochromia requires at least 2 to 4 hours after onset
Monitoring labs during ED treatment
Safety monitoring during treatment
Renal function if ketorolac planned for patients with baseline renal risk
Potassium for patients receiving repeated metoclopramide
Diphenhydramine safety check — urinary retention risk in elderly men
Blood pressure monitoring after chlorpromazine — orthostatic hypotension risk
Diagnostic Tests
Scoring Systems
ICHD-3 diagnostic criteria for migraine without aura
A — at least 5 attacks fulfilling criteria B to D
B — duration 4 to 72 hours untreated or unsuccessfully treated
C — at least 2 of: unilateral, pulsating, moderate to severe pain, worsening with activity
D — at least 1 of: nausea or vomiting, photophobia and phonophobia
E — not better accounted for by another ICHD-3 diagnosis
ICHD-3 criteria for migraine with aura
At least 2 attacks with fully reversible aura
At least 1 positive aura symptom spreading at 5 mm per minute over 5 minutes
Each symptom lasting 5 to 60 minutes
Headache accompanying or following aura within 60 minutes
ID Migraine screening tool
Three questions: disability, nausea, photosensitivity
Sensitivity 81%, specificity 75% for migraine diagnosis in primary care
MIDAS — Migraine Disability Assessment
Five questions about headache days with disability in past 3 months
Grade I — 0 to 5 minimal, Grade II — 6 to 10 mild, Grade III — 11 to 20 moderate, Grade IV — 21 or more severe
Guides preventive therapy initiation threshold
HIT-6 — Headache Impact Test
Six questions about headache impact on function
Score 60 or above indicates substantial or severe impact
Ottawa subarachnoid hemorrhage rule
For alert patients with non-traumatic headache reaching maximum intensity within 1 hour
High sensitivity for SAH — 100% in derivation cohort
Indications for CT head — age 40 or above, neck pain or stiffness, witnessed loss of consciousness, onset with exertion, thunderclap quality, limited neck flexion on exam
MRI
MRI head indications in migraine evaluation
Atypical aura features — motor weakness, prolonged aura over 60 minutes
New or changed headache pattern requiring exclusion of secondary cause
Hemiplegic migraine — structural and metabolic cause exclusion
Aura without headache, especially in older patients
MRI sequences and findings
MRI without contrast — preferred initial sequence for headache
FLAIR — white matter hyperintensities in migraine with aura, more common than controls
DWI — acute stroke differentiation from prolonged aura
MR angiography — cerebral vasculature for RCVS, dissection, aneurysm
MR venography — cerebral venous sinus thrombosis
Migraine-specific MRI findings
White matter T2 hyperintensities — prevalence increased with aura history
No acute infarct on DWI differentiates aura from stroke
MRI superior to CT for posterior fossa and brainstem lesions
MRI normal in uncomplicated migraine — does not exclude diagnosis
CT
CT head without contrast indications
Thunderclap headache — sensitivity 98% within 6 hours of onset for SAH
Focal neurologic deficits
New headache after age 50
Posttraumatic headache
Signs of increased intracranial pressure
Altered mental status
CT head limitations
Sensitivity for SAH falls to 85% to 90% at 24 hours and further declines
Poor sensitivity for posterior fossa lesions
Negative CT does not exclude SAH — LP required when pretest probability high
CT angiography indications
Ottawa positive rule with negative CT — CTA or LP next step
Suspected RCVS — beaded appearance of cerebral arteries
Carotid or vertebral artery dissection suspected
Aneurysm detection — sensitivity 95% to 97% for aneurysms over 3 mm
CT perfusion
Not routine for migraine evaluation
Role in complex aura or spreading cortical depression research
Ultrasound
Point-of-care ultrasound applications
Optic nerve sheath diameter
Greater than 5 mm indicates elevated intracranial pressure
Sensitivity 74%, specificity 87% for ICP elevation greater than 20 cmH2O
Rapid bedside assessment when papilledema suspected
Temporal artery ultrasound
Halo sign — hypoechoic ring around artery in giant cell arteritis
Sensitivity 75% to 87% for GCA
May replace biopsy in high-probability cases per some guidelines
Transcranial Doppler
Vasospasm detection in RCVS and post-SAH monitoring
Not routine for acute migraine in ED
Greater occipital nerve identification
Ultrasound-guided occipital nerve block technique
Improves accuracy of nerve block procedure
Disposition
Discharge criteria
Safe discharge requirements
Pain controlled to tolerable level — not necessarily pain-free
Tolerating oral fluids and discharge medications
Normal neurological examination throughout visit
No red flags or secondary headache features identified
Reliable follow-up plan with primary care or neurology
Responsible adult available for patients given sedating medications
Admission indications
Inpatient admission triggers
Status migrainosus — headache persisting more than 72 hours refractory to ED treatment
Intractable vomiting and dehydration requiring IV fluid replacement beyond ED capacity
IV dihydroergotamine protocol requirement — typically 2 to 3 day inpatient course
Concern for secondary headache requiring inpatient neuroimaging or LP
Significant psychiatric comorbidity including suicidal ideation
Inadequate social support for safe home management
Transfer criteria
Neurology or neurosurgery transfer indications
Confirmed or suspected SAH — immediate neurosurgical consultation
Gammacore noninvasive vagus nerve stimulator — for migraine and cluster headache
Non-invasive transcranial magnetic stimulation — SpringTMS — for aura treatment
Patient Discharge Instructions
copy discharge instructions
What you were treated for
You were treated in the emergency department for a migraine headache
Migraine is a neurological condition causing severe head pain with nausea, light and sound sensitivity
Tests were performed to ensure no serious or dangerous cause of your headache
Medications prescribed or recommended
Take ibuprofen 400 to 600 mg by mouth with food every 6 to 8 hours as needed for pain
Take acetaminophen 1000 mg by mouth every 6 hours as needed if NSAIDs are not suitable
If a triptan was prescribed, take at the first sign of headache for best results
If anti-nausea medication was prescribed, take it as directed
Do not take more than the recommended amount of pain medications
Medication warnings
Limit use of pain relievers to fewer than 15 days per month
Limit triptan use to fewer than 10 days per month
Using pain medications too often can cause medication overuse headache — more frequent headaches
Avoid opioids and narcotics for headache unless specifically directed by your physician
Home care instructions
Rest in a dark and quiet room during attacks
Apply ice pack or cold cloth to forehead or neck
Drink adequate fluids to stay hydrated
Avoid known triggers — alcohol, skipped meals, irregular sleep
Keep a headache diary — write down when headaches occur and what may have triggered them
When to return to the emergency department immediately
Sudden severe headache that is the worst of your life
Headache with fever and stiff neck
New weakness, numbness, difficulty speaking, or vision changes
Headache significantly different from your usual migraine
Persistent vomiting and inability to keep fluids down
Seizure
Worsening despite prescribed medications
Headache after a head injury
Follow-up plan
Follow up with your family doctor or headache specialist within 1 to 2 weeks
If headaches are frequent or severely impacting your life, ask about preventive medications
Bring your headache diary to your follow-up appointment
References
Guidelines and key sources
Robbins MS — Diagnosis and Management of Headache: A Review — JAMA 2021
Comprehensive clinical review covering ICHD-3 criteria, acute and preventive treatment
Ashina M — Migraine — New England Journal of Medicine 2020
Pathophysiology, epidemiology, treatment review — landmark NEJM clinical practice article
Ailani J, Burch RC, Robbins MS — American Headache Society Consensus Statement 2021
Update on integrating new migraine treatments into clinical practice — Headache 2021
Robblee J, Minen MT, Friedman BW et al — 2025 AHS Guideline Update
Acute treatment of migraine in emergency department — parenteral pharmacotherapies — Headache 2025
Qaseem A et al — ACP Clinical Guideline 2025
Pharmacologic treatments of acute episodic migraine — Annals of Internal Medicine 2025
Do TP et al — Red and Orange Flags for Secondary Headaches — SNNOOP10 List — Neurology 2019
ACOG Clinical Practice Guideline No. 3 — Headaches in Pregnancy and Postpartum — 2022
VanderPluym JH et al — Acute Treatments for Episodic Migraine — JAMA 2021
Systematic review and meta-analysis of acute migraine treatments
GBD 2023 Headache Collaborators — Global burden of headache disorders — Lancet Neurology 2025
Ashina M et al — Migraine: Epidemiology and Systems of Care — Lancet 2021
Hugger SS et al — Migraine in Older Adults — Lancet Neurology 2023
Rodriguez JP et al — Magnesium Supplementation for Migraine Prophylaxis — Cochrane Review 2025
Orr SL et al — Management of Adults with Acute Migraine in the ED — Headache 2016
VA/DoD Clinical Practice Guideline for Management of Headache 2023
SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.