Migraines and Red Flags

1. Diagnostic Criteria for Migraine without Aura

  • Headache attacks lasting 4 – 72 hours (untreated or unsuccesfsfully treated)
  • Headache has at least two of the following characteristics
    • Unilatral location
    • Pulsating quality
    • Moderate or severe pain intensity
    • Aggravation by or causing avoidance of routine physical activity
  • During headache at least one of the following
    • nausea, vomiting, or both
    • Photophobia and phonophobia
  • At least 5 attacks fulfilling the above criterion
  • Not better accounted for by another diagnosis

2. Red Flag Signs and Symptoms in Acute Headache with diagnoses to consider

  • First or worse headache of life (CNS infection, intracranial hemorrhage)
  • Focal neurologic signs (AV malformation, collagen vascular dz, intracranial mass lesion)
  • HA triggered by cough or exertion (mass lesion, SAH)
  • Change in mental status or personality (CNS infection, intracerebral bleed, mass lesion)
  • Neck stiffness or meningismus (meningitis)
  • Severe HA in pregnancy or post-partum (cranial sinus thrombosis, carotid artery dissection, pituitary apoplexy)
  • Older than 50 years (mass lesion, temporal arteritis)
  • Papilledema (encephalitis, mass lesion, meningitis, pseudotumor cerebri)
  • Rapid onset with strenuous exercise (carotid artery dissection, intracranial bleed)
  • Sudden onset with max intensity within seconds “Thunderclap” (SAH, bleeding into mass)
  • Systemic illness with HA (arteritis, collagen vascular dz, encephalitis, meningitis)
  • Tenderness over temporal artery (Polymyalgia rheumatica, temporal arteritis)

3. Treatment of acute severe migraine

  • Sumatriptan 6mg SQ OR Antiemetic IV (metoclopramide, prochlorperazine, or chlorpromazine)
  • If giving parenteral anti-emetics, give adjunct diphenhydramine to prevent akathisia and other dystonic reactions
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