Migraine HeadacheMANAGEMENT

NEUROLOGICAL PRESENTATIONS · 12 SECTIONS

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670 items

☷ Legend

01Approach to the Critical Patient/attcp34

Immediate priorities

›Red flag identification

›Thunderclap headache — maximal intensity within seconds

›>40% pretest probability for SAH or RCVS

›Emergent CT head then LP if CT negative

›Fever with meningismus

›Nuchal rigidity, Kernig sign, Brudzinski sign

›Immediate LP consideration after CT if no papilledema

›Focal neurologic deficits not consistent with aura

›Persistent motor weakness — stroke protocol

›Sudden onset speech disturbance — activate stroke alert

›Papilledema with impaired consciousness

›Intracranial hypertension protocol

›Emergent neurosurgical or neurology consult

Hemodynamic and monitoring targets

›Vital sign targets

›Blood pressure below 160/100 mmHg if hypertensive urgency suspected

›SpO2 > 94% on room air

›Heart rate within normal range for comfort measures

›Mental status monitoring

›GCS at triage and reassessment after treatment

›If GCS < 14, neuroimaging before analgesics

›Pain and antiemetic response

›Pain score reassessment at 30 and 60 minutes post-treatment

›Vomiting control required before oral therapy

Escalation triggers

›Neuroimaging indications

›New headache after age 50

02History/hx73

Headache characterization

›Pain quality and severity

›Unilateral location — approximately 60% of attacks

›Pulsating or throbbing quality

›Moderate to severe intensity

›Duration 4 to 72 hours untreated

›Associated symptoms

›Nausea and vomiting

›Photophobia

›Phonophobia

›Osmophobia — intolerance to smells

›Worsening with physical activity

Aura and migraine phases

›Premonitory phase

›Mood changes — irritability or euphoria

›Neck pain and stiffness

›Food cravings

›Polyuria

›Yawning — hours before headache onset

›Aura features

›Visual — scintillations, fortification spectra, scotoma

›Sensory — paresthesias with gradual march over minutes

›Speech disturbance — dysphasia developing over 5 to 20 minutes

›Aura duration 5 to 60 minutes preceding headache

›Aura present in approximately 25% to 30% of migraine patients

›Postdrome

›Fatigue and cognitive fog after headache resolves

›Difficulty concentrating lasting hours to one day

Alarm features — SNNOOP10 mnemonic

›Systemic features

›Fever

›Unintentional weight loss

›Known malignancy or immunosuppression

›Neurologic signs

›Focal deficits not typical for personal aura pattern

›Altered consciousness

›Papilledema

›Onset pattern

›Thunderclap onset — maximal within seconds to minutes

›New onset after age 50 — consider giant cell arteritis and neoplasm

›Onset with exertion, cough, Valsalva, or sexual activity

›Other patterns

›Positional component — suspect intracranial hypo or hypertension

›Pregnancy or postpartum — cerebral venous sinus thrombosis, preeclampsia, arterial dissection

›Posttraumatic onset — subdural hematoma

›Progressive worsening — mass lesion concern

Triggers and pattern

›Common triggers

›Sleep disruption — excess or deprivation

›Skipped meals and fasting

›Stress and emotional upset

›Weather and barometric pressure changes

›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

03Physical Exam/exam38

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

04Differential Diagnosis/ddx55

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

05Laboratory Tests/lt33

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

06Diagnostic Tests/dt75

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 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

07Disposition/dispo24

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

›Cerebral venous sinus thrombosis requiring anticoagulation initiation

›Unruptured intracranial aneurysm detected incidentally

›Hypertensive encephalopathy or PRES requiring monitored setting

Outpatient follow-up planning

›Follow-up timing after ED visit

›Primary care or headache specialist within 1 to 2 weeks

›Neurology referral for — diagnostic uncertainty, failure of 2 or more preventive medications, atypical aura, hemiplegic migraine

›After starting preventive therapy — reassess at 6 to 8 weeks

›Chronic migraine with preventive therapy — every 1 to 3 months

08Treatment/t123

Immediate ED management

›Initial supportive measures

›Dark and quiet environment when possible

›IV access and normal saline 500 to 1000 mL for dehydration

›Antiemetic before or with analgesic for nausea

›Diphenhydramine 25 to 50 mg IV co-administration with dopamine antagonists

›Reduces akathisia and extrapyramidal symptoms

›Administer with prochlorperazine or metoclopramide routinely

First-line parenteral therapy — AHS 2025 Level A

›Prochlorperazine IV — Level A Must Offer

›Dose 10 to 12.5 mg IV over 15 minutes

›Mechanism — dopamine D2 receptor antagonism

›Effective for both pain and nausea

›Co-administer diphenhydramine 25 mg IV to prevent akathisia

›Akathisia incidence without prophylaxis approximately 20%

›Greater occipital nerve block — Level A Must Offer

›Bupivacaine 0.5% 2.5 mL each side or lidocaine 1% 2 to 3 mL each side

›Injection at medial third of line between occipital protuberance and mastoid

›Response rate 55% to 75% at 30 minutes

›Particularly useful for posterior-dominant or occipital migraine

›Ultrasound guidance improves accuracy

Second-line parenteral therapy — AHS 2025 Level B

›Metoclopramide IV — Level B Should Offer

›Dose 10 mg IV over 15 minutes

›Anti-dopaminergic and prokinetic mechanism

›Co-administer diphenhydramine 25 mg IV

›Avoid in suspected bowel obstruction

›Ketorolac IV — Level B Should Offer

›Dose 15 to 30 mg IV or 30 to 60 mg IM

›Reduce dose to 15 mg IV in patients over 65, low body weight, or renal impairment

›Limit to 5 days total cumulative use

›Avoid in renal failure, peptic ulcer disease, pregnancy after 20 weeks

›Sumatriptan SC — Level B Should Offer

›Dose 6 mg SC

›Contraindicated in CAD, stroke, PVD, hemiplegic migraine, basilar migraine

›May repeat once after 1 hour if initial response partial

›Supraorbital nerve block — Level B Should Offer

›Lidocaine 1% or bupivacaine 0.25% 1 to 2 mL at supraorbital notch

Third-line parenteral therapy — AHS 2025 Level C

›Chlorpromazine IV — Level C May Offer

›Dose 12.5 to 25 mg IV slow push over 20 minutes

›Orthostatic hypotension risk — saline preload and supine positioning required

›BP monitoring at 15, 30, and 60 minutes

›Dexamethasone IV — Level C May Offer for recurrence prevention

›Dose 10 mg IV single dose

›Not for acute pain control — reduces 24 to 72 hour headache recurrence

›Recurrence rate reduction from 45% to 26% when added to abortive therapy

›Valproate IV — Level C May Offer

›Dose 500 to 1000 mg IV over 15 minutes

›Absolute contraindication in pregnancy — teratogenic

›Monitor for hyperammonemia in prolonged use

Medications to avoid

›Hydromorphone IV — Level A Must NOT Offer

›Inferior efficacy to dopamine antagonists in head-to-head trials

›Higher risk of dependency, medication overuse headache

›Worsens long-term headache outcomes

›IV acetaminophen — Level C Should NOT Offer for pain relief

›Opioids in general — inferior efficacy, dependency risk, medication overuse headache

›Associated with progression from episodic to chronic migraine

IV dihydroergotamine protocol — inpatient

›DHE 45 dosing

›Test dose 0.5 mg IV over 3 minutes to assess tolerability

›Full dose 1 mg IV over 3 minutes every 8 hours for up to 2 to 3 days

›Premedicate with metoclopramide 10 mg IV 30 minutes before each dose

›Contraindicated in pregnancy, uncontrolled hypertension, CAD, hemiplegic migraine

Outpatient acute therapy

›Mild to moderate attacks — 2025 ACP guideline

›NSAIDs first-line

›Ibuprofen 400 to 600 mg PO

›Naproxen sodium 550 mg PO

›Aspirin 500 to 1000 mg PO

›Acetaminophen 1000 mg PO — alternative if NSAIDs contraindicated

›Moderate to severe attacks — triptans

›Sumatriptan 50 to 100 mg PO or 6 mg SC or 20 mg intranasal

›Rizatriptan 10 mg PO — fastest onset among oral triptans

›Eletriptan 40 mg PO — high efficacy in head-to-head comparisons

›Sumatriptan plus naproxen sodium — combination superior to monotherapy

›Pain freedom at 2 hours: combination 26% vs sumatriptan 16% vs naproxen 10%

›Triptan failure or contraindication alternatives

›Gepants — CGRP receptor antagonists

›Ubrogepant 50 to 100 mg PO — may repeat once after 2 hours

›Rimegepant 75 mg PO — also approved for preventive use

›Zavegepant 10 mg intranasal

›No cardiovascular contraindications — safe in CAD and stroke patients

›Lasmiditan 50 to 200 mg PO

›Serotonin 1F receptor agonist — no vasoconstriction

›No drive or operate machinery for 8 hours after dose

›Schedule V controlled substance

Preventive therapy

›Indications for preventive therapy

›6 or more headache days per month

›4 or more days per month with significant impairment

›3 or more days per month with severe impairment

›Failure to respond to or contraindication to acute treatments

›Patient preference for prevention over acute treatment

›First-line oral preventives

›Propranolol 40 to 160 mg PO daily — titrate from 40 mg twice daily

›Preferred if concurrent anxiety, tremor, or hypertension

›Contraindicated in asthma, COPD, and second to third degree heart block

›Metoprolol succinate 50 to 200 mg PO daily

›Topiramate 25 to 100 mg PO daily — titrate 25 mg per week

›Preferred if concurrent obesity — weight loss side effect

›Teratogenic — contraception required in women of childbearing age

›Cognitive side effects — word-finding difficulty

›Divalproex sodium 500 to 1000 mg PO daily

›Teratogenic — avoid in pregnancy

›Monitor LFTs and CBC

›Amitriptyline 10 to 75 mg PO nightly

›Preferred if concurrent insomnia, depression, or tension-type overlay

›Anticholinergic effects — dry mouth, constipation, urinary retention

›CGRP-targeted preventive therapies

›Anti-CGRP monoclonal antibodies — monthly to quarterly SC or IV

›Erenumab 70 to 140 mg SC monthly

›Fremanezumab 225 mg SC monthly or 675 mg SC quarterly

›Galcanezumab 240 mg SC loading then 120 mg SC monthly

›Eptinezumab 100 to 300 mg IV quarterly

›Indicated after failure of 2 or more oral preventives

›Oral gepants for prevention

›Atogepant 10 to 60 mg PO daily

›Rimegepant 75 mg PO every other day

›Chronic migraine specific

›OnabotulinumtoxinA 155 units IM every 12 weeks

›FDA-approved for 15 or more headache days per month

›31 injection sites across head and neck muscles

›Response takes 2 to 3 treatment cycles

›Supplements with evidence

›Magnesium 400 to 800 mg PO daily

›Cochrane 2025 review supports prophylactic benefit

›Particularly effective in menstrual migraine

›Riboflavin 400 mg PO daily

›Coenzyme Q10 300 mg PO daily

09Special Populations/sp83

Pregnancy

›Pregnancy-specific risk assessment

›New or changed headache in pregnancy — secondary causes must be excluded

›Preeclampsia — blood pressure over 140/90 mmHg with proteinuria or end-organ damage

›Hypertensive encephalopathy manifestation

›Urgent obstetric evaluation required

›Cerebral venous sinus thrombosis — highest risk in postpartum period

›Diagnosis by MR venography — avoid gadolinium in first trimester if possible

›Posterior reversible encephalopathy syndrome — PRES in setting of severe hypertension

›Acute treatment in pregnancy

›Safest agents — acetaminophen 1000 mg PO

›First-line for all trimesters

›NSAIDs — use with caution

›Avoid after 20 weeks gestation due to premature ductus arteriosus closure risk

›Avoid in first trimester if possible — gastroschisis risk data

›Metoclopramide 10 mg IV or PO — generally considered safe

›Prochlorperazine — limited data but used clinically in second and third trimester

›Triptans — not recommended; limited safety data, vasoconstrictive concerns

›ACOG 2022 guideline — sumatriptan may be used cautiously in refractory cases after risk-benefit discussion

›Opioids — avoid; dependency and neonatal withdrawal risk

›Ergotamines — absolutely contraindicated; uterotonic and vasoconstrictive

›Preventive treatment in pregnancy

›Propranolol — most evidence in pregnancy; monitor for fetal bradycardia and growth restriction

›Amitriptyline — low-dose generally considered acceptable; monitor neonatal adaptation

›Valproate — absolutely contraindicated; major teratogen, neurodevelopmental harm

›Topiramate — avoid; cleft palate and small for gestational age risk

›CGRP monoclonal antibodies — contraindicated; inadequate safety data

›Magnesium supplementation — safe; additional benefit in preeclampsia prevention

Geriatric

›Age-related diagnostic considerations

›Migraine typically decreases in frequency after age 50 to 60

›New headache after age 50 requires secondary cause exclusion

›Giant cell arteritis — primary concern for new temporal headache

›ESR and CRP mandatory

›Do not delay steroids if GCA suspected — vision loss risk

›Migraine with aura in older adults may mimic TIA

›Key differentiator — aura spreads gradually over minutes with positive symptoms

›TIA is maximal at onset and negative symptoms predominate

›Treatment modifications in elderly

›Triptans — use with caution; increased cardiovascular risk with age

›Contraindicated if any cardiovascular disease history

›Gepants preferred alternative — no vasoconstrictive effects

›NSAIDs — increased risk of GI bleeding, renal impairment, and heart failure

›Lowest effective dose for shortest duration

›Proton pump inhibitor co-prescription recommended

›Prochlorperazine and metoclopramide — increased extrapyramidal side effects

›Tardive dyskinesia risk with prolonged use

›Reduce dose to 5 mg IV in those over 65

›Amitriptyline — avoid; Beers Criteria caution; anticholinergic burden

›Nortriptyline preferred if tricyclic required — less anticholinergic

›Falls risk — sedating antiemetics and analgesics require monitored ambulation

›Migraine in older adults — epidemiology

›Prevalence 3% to 5% in adults over 70

›Migraine aura equivalent without headache — more common with advancing age

›Acephalgic migraine may be misdiagnosed as TIA

Pediatrics

›Pediatric migraine features

›Prevalence — 3% before puberty rising to 11% by mid-adolescence

›Duration shorter than adults — 1 to 72 hours acceptable for ICHD-3 diagnosis

›Often bilateral location in younger children — unlike adult unilateral pattern

›Nausea and vomiting prominent features

›Migraine equivalents — cyclic vomiting syndrome, abdominal migraine, benign paroxysmal vertigo

›Acute treatment in pediatrics

›Ibuprofen 10 mg per kg PO — first-line for mild to moderate attacks

›Maximum 400 mg per dose

›Evidence level — Level A recommendation

›Acetaminophen 15 mg per kg PO — alternative

›Triptans FDA-approved for pediatric use

›Almotriptan — approved age 12 and above

›Rizatriptan — approved age 6 and above, 5 mg for 20 to 39 kg; 10 mg for 40 kg or above

›Sumatriptan nasal spray 10 mg — approved age 12 and above

›Zolmitriptan nasal spray 2.5 mg — approved age 12 and above

›Prochlorperazine 0.1 to 0.15 mg per kg IV — maximum 10 mg

›Metoclopramide 0.1 mg per kg IV — maximum 10 mg

›Ketorolac 0.5 mg per kg IV — maximum 15 mg

›Preventive treatment in pediatrics

›Indicated when 4 or more headache days per month with impairment

›Topiramate — FDA-approved for adolescents 12 and above; start 15 to 25 mg daily

›Propranolol — evidence supports use in children over 6; 1 to 3 mg per kg per day in divided doses

›Amitriptyline — commonly used; limited controlled trials; 0.1 to 2 mg per kg nightly

›CGRP monoclonal antibodies — not FDA-approved under 18; limited data

›Non-pharmacological — biofeedback, CBT, and sleep hygiene have strong evidence in children

›Pediatric alarm features

›Occipital headache in child — posterior fossa lesion until excluded

›Early morning headache with vomiting — hydrocephalus or mass

›Headache causing awakening from sleep

10Background/b78

Epidemiology

›Global burden

›Prevalence approximately 12% of general population

›17% of women and 6% of men affected

›Second leading cause of disability worldwide — GBD 2023 data

›Estimated 1 billion people affected globally

›Age and sex distribution

›Peak prevalence age 20 to 50 years

›Female to male ratio 3:1 — hormonal influence

›Onset commonly in second and third decades

›Prevalence declines after age 50, especially after menopause

›Subtypes and classification

›Episodic migraine — fewer than 15 headache days per month

›Chronic migraine — 15 or more headache days per month for 3 or more months

›At least 8 days per month meeting migraine criteria

›Affects approximately 2% of population

›Migraine with aura affects 25% to 30% of migraine patients

›Migraine without aura — most common subtype

›Economic and social impact

›Annual direct and indirect costs estimated 17 billion USD in the United States

›Average 4.9 disability days per episode in employed patients

›Leading cause of disability in adults under age 50

Pathophysiology

›Cortical spreading depression

›Wave of neuronal and glial depolarization propagating across cortex at 3 to 5 mm per minute

›Correlates with visual aura — begins in occipital cortex

›Triggers trigeminal pain pathway activation

›Followed by sustained suppression of neural activity

›Trigeminovascular pathway

›Trigeminal nerve innervates meningeal blood vessels

›Activation releases CGRP — calcitonin gene-related peptide

›CGRP causes vasodilation and neurogenic inflammation of meningeal vessels

›Serum CGRP elevated during migraine attacks

›CGRP levels normalize after triptan treatment

›Central sensitization develops in prolonged attacks — allodynia manifestation

›Scalp tenderness to non-painful stimuli during attack

›CGRP and serotonin pathways

›5-HT1B/1D agonism — mechanism of triptans and DHE

›Vasoconstriction of dilated meningeal vessels

›Inhibition of CGRP release from trigeminal terminals

›Dopamine antagonism — mechanism of prochlorperazine and metoclopramide

›Modulates brainstem pain processing

›CGRP receptor blockade — mechanism of gepants

›No vasoconstriction — safer in cardiovascular disease

›Genetics

›Strong heritable component — first-degree relatives have 2 to 4 times increased risk

›Familial hemiplegic migraine — CACNA1A, ATP1A2, SCN1A mutations

›Common migraine — polygenic; GWAS identified over 40 susceptibility loci

›TRPM8 gene — cold and menthol sensation — associated with migraine risk

›Hypothalamic involvement

›Premonitory symptoms initiated in hypothalamus

›Hypothalamic activation precedes headache onset by hours on neuroimaging

›Explains circadian and hormonal migraine patterns

Therapeutic Considerations

›Treatment stratification approach

›Step care — all patients start with NSAIDs then advance if ineffective

›Stratified care — treat attack based on severity — moderate to severe with triptan first

›Evidence favors stratified care for faster relief and fewer treatment steps

›Medication overuse headache prevention

›Triptans and ergots — limit to 10 days per month maximum

›NSAIDs and acetaminophen — limit to 15 days per month maximum

›Opioids and barbiturates — highest risk; limit to 10 days per month

›Gepants and lasmiditan — no established medication overuse threshold based on current data

›Lifestyle modifications — SEEDS mnemonic

›Sleep — regular sleep schedule; avoid excess or deprivation

›Exercise — 30 minutes aerobic exercise 3 times per week reduces frequency

›Eating — regular meals; avoid skipping; adequate hydration

›Diary — headache diary identifies triggers and measures treatment response

›Stress management — mindfulness-based stress reduction, CBT

›CGRP pathway as therapeutic target

›CGRP elevated during all phases of migraine attack

›Anti-CGRP antibodies demonstrated 50% responder rate of 45% to 60% in trials

›Gepants target receptor rather than ligand — suitable for frequent dosing

›Lasmiditan targets 5-HT1F receptor — pain modulation without vasoconstriction

›Interventional approaches

›Greater occipital nerve block — AHS Level A in acute ED setting

›Sphenopalatine ganglion block — intranasal catheter approach

›Response rate 55% in acute ED setting

›Neuromodulation — Cefaly external trigeminal nerve stimulator FDA-cleared

›Gammacore noninvasive vagus nerve stimulator — for migraine and cluster headache

›Non-invasive transcranial magnetic stimulation — SpringTMS — for aura treatment

11Patient Discharge Instructions/pdi34

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

12References/r20

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

Learn More: Migraine Headache→

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Reviewed by SymptomDx Medical Team · Last reviewed August 18, 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.