Migraine

Migraine - Acute
Rahul Soman, M. Pharm

 

Definition  

A primary episodic headache disorder characterized by various combinations of neurological, gastrointestinal, and autonomic changes . Migraines may have common (without aura), classic (with aura), or complex (basilar, hemiplegic, ophthalmoplegic, abdominal) presentations.

 

Medical History  

* Dietary intake finding

* Alcohol intake - finding

* Menstruation finding

* Hormonal Contraceptive use

* Menopause

* Estrogen/Progestin Combination use

* Antihypertensive use

* Exercise history finding

* Whiplash injury to neck

* Blunt head trauma [Blunt head trauma - Acute]

* Smoking

* Cocaine abuse

* Environmental finding

* Family history of Migraine

 

Findings  

* Headache

* Nausea

* Mood disorder

* Vomiting

* Light intolerance

* Blurred vision

* Tachyarrhythmia

* Visual obscuration

* Visual field defect

* Pain in eye

* Noise intolerance

* Abdominal pain - Acute

* Abdominal distension, gaseous

* Aphasia

* Carotid artery finding

* Fatigue

* Paresthesia

* Scalp tenderness

* Weight gain

* Hyperventilation - Acute

* Edema - Acute

* Engorgement of vein

* Altered mental status

* Ataxia

* Chest pain - Acute

* Pallor

* Nuchal rigidity

* Myalgia

* Vertigo - Acute

* Syncope - Acute

* Hypesthesia

* Hemiplegia

* Nasal congestion

* Diarrhea

* Seizure

* Homonymous hemianopia

* Third cranial nerve weakness

* Diplopia

* Dysarthria

* Neck pain

* Increased body temperature

 

Tests  

 

Headache  

* Imaging by body site, Entire brain: Neuroimaging may aid in differential diagnosis of some patients by ruling out specific intracranial abnormalities , but is not universally recommended in all patients with all headache types .

 

Suspected subarachnoid hemorrhage in patients with a negative or equivocal head CT scan  

* Cerebrospinal fluid examination: Findings consistent with subarachnoid hemorrhage include elevated opening pressure, elevated RBC count that does not diminish in successive tubes, and xanthochromia .

 

Meningitis  

* Cerebrospinal fluid examination

 

Suspected giant cell (temporal) arteritis  

* Erythrocyte sedimentation rate measurement: Erythrocyte sedimentation rate is elevated in most, but not all, patients with giant cell arteritis; a normal result does not exclude disease .

 

Differential Diagnosis  

* Subarachnoid hemorrhage

* Thromboembolic stroke

* Transient ischemic attack - Acute

* Intracranial hemorrhage

* Bacterial meningitis - Acute

* Viral meningitis - Acute

* Viral encephalitis - Acute

* Temporal arteritis

* Intracranial tumor

* Carotid artery dissection

* Vertebral artery dissection

* Cluster headache - Acute

* Abscess of brain - Acute

* Hydrocephalus

* Pseudotumor cerebri - Acute

* Trigeminal neuralgia - Acute

* Sinusitis - Acute

* Tension-type headache

* Temporomandibular joint-pain-dysfunction syndrome

* Optic neuritis

* Postconcussion syndrome

* Amaurosis fugax

* Low pressure headache

* Vasculitis

* Pheochromocytoma - Acute

* Glaucoma - Acute

 

Treatment  

 

Drug Therapy  

 

Status migrainous or severe migraine in adults  

 

PROCHLORPERAZINE - DIHYDROERGOTAMINE MESYLATE  

Adults: Prochlorperazine 10 mg IV over 2 to 3 minutes once AND dihydroergotamine 0.5 to 1 mg IV over 5 minutes; repeat 0.5 to 1 mg IV every hours if headache persists (maximum dose, 3 mg/day) approximately 10 minutes after pretreatment with an antiemetic

 

CHLORPROMAZINE HYDROCHLORIDE - DIHYDROERGOTAMINE MESYLATE  

Adults: Chlorpromazine 7.5 to 1 mg IV boluses over 3 minutes every 7 to 10 minutes (maximum total dose 30 mg) AND dihydroergotamine 0.5 to 1 mg IV over 5 minutes; repeat 0.5 to 1 mg IV every hours if headache persists (maximum dose, 3 mg/day) approximately 10 minutes after pretreatment with an antiemetic

 

Moderate to severe migraine in adults  

 

KETOROLAC TROMETHAMINE  

Adults (<65 years): 60 mg IM or 30 mg IV as a single dose OR 30 mg IV or IM every 6 hours (maximum 120 mg/day for  5 days)

 

MEPERIDINE HYDROCHLORIDE  

Adults: 50 to 150 mg IM every 4 hours as needed (maximum 400 mg)

 

PROCHLORPERAZINE  

Adults: 10 mg IV over 2 to 3 minutes once OR 5 to 10 mg IM every 4 hours, alone or as adjunct therapy

 

DIHYDROERGOTAMINE MESYLATE  

Adults: 1 mg IM; may repeat twice every 4 hours to total of 3 mg/attack OR 1 mg subQ; may repeat every hour to total of 3 mg/attack OR: 0.5 mg intranasally; repeat after 15 min (maximum, 3 mg/24 hours)

 

SUMATRIPTAN  

Adults: 6 mg subQ in lateral thigh; may repeat in 1 hour (maximum 12 mg/day) OR: 5 to 20 mg intranasally; may repeat once after 2 hours (maximum dose 40 mg/day) OR 25 to 100 mg orally; may repeat in 2 hours (maximum 200 mg/day)

 

ZOLMITRIPTAN  

Adults: 2.5 or 5 mg orally; may repeat in 2 hours (maximum 10 mg/day) OR 5 mg intranasally into 1 nostril; may repeat once after 2 hours (maximum 10 mg/day)

 

NARATRIPTAN HYDROCHLORIDE  

Adults: 1-mg or 2.5-mg tablet orally; may repeat once after 4 hours (maximum 5 mg/day)

 

RIZATRIPTAN BENZOATE  

Adults: 5 or 10 mg tablet or wafer; may repeat in 2 hours if needed (maximum 30 mg/day) OR for patients using propranolol prophylactically 5 mg tablet or wafer; may repeat in 2 hours (maximum 15 mg/day)

 

FROVATRIPTAN SUCCINATE  

Adults: 2.5 or 5 milligrams; may repeat in 2 hours if headache returns (maximum 7.5 mg/day)

 

ELETRIPTAN HYDROBROMIDE  

Adults: Initial 20 to 40 mg orally; may repeat after 2 hours if headache returns (maximum single dose 40 mg, maximum daily dose 80 mg)

 

ALMOTRIPTAN MALATE  

Adults: 6.25 to 12.5 mg orally; may repeat after 2 hours (maximum 2 doses/day)

 

ACETAMINOPHEN / ASPIRIN / CAFFEINE  

Adults: 2 tablets orally every 6 hours while symptoms persist (maximum 8 tablets or caplets in 24 hours) or as directed by a physician (maximum no more than 48 hours for pain of migraine)

 

 

Mild to moderate migraine in adults  

 

ACETAMINOPHEN / ASPIRIN / CAFFEINE  

Adults: 2 tablets orally every 6 hours while symptoms persist (maximum 8 tablets or caplets in 24 hours) or as directed by a physician (maximum no more than 48 hours for pain of migraine)

 

IBUPROFEN

Adults: 400 mg orally every 4 to 6 hours as needed (maximum 3.2 g/day) OR 600 to 1200 mg orally at onset then 400 to 600 mg orally in 1 hour (maximum 2.4 g/day)

 

NAPROXEN SODIUM  

Adults: 275 to 825 mg orally loading dose, followed by 275 mg orally every 4 hours (maximum 1250 mg/day)

 

ASPIRIN

Adults: 500 to 1000 mg orally every 4 to 6 hours (maximum 4 g/day)

 

 

Migraine in children  

 

ACETAMINOPHEN

Pediatrics: 15 mg/kg; repeat once after 2 hours, then every 4 to 6 hours (maximum total dose, 100 mg/day)

 

IBUPROFEN

Pediatrics: 10 mg/kg orally every 6 to 8 hours as needed (maximum 40 mg/kg/day) OR 10 mg/kg orally; may repeat once after 2 hours then every 4 to 6 hours (maximum 40 mg/kg/day)

 

Acute migraine with nausea and vomiting  

 

PROCHLORPERAZINE  

Adults: 5 to 10 mg IM every 4 hours OR 25 mg rectally twice daily, alone or as adjunct therapy

Pediatrics (<12 years): 0.06 mg/lb deep IM, alone or as adjunct therapy

Pediatrics (>2 years, 40 to 85 lb): 2.5 mg rectally 3 times daily or 5 mg rectally twice daily, alone or as adjunct therapy (maximum 15 mg/day)

Pediatrics (>2 years, 30 to 39 lb): 2.5 mg rectally 2 or 3 times daily, alone or as adjunct therapy (maximum 10 mg/day)

Pediatrics (>2 years, 20 to 29 lb): 2.5 mg rectally once or twice daily, alone or as adjunct therapy (maximum 7.5 mg/day)

 

CHLORPROMAZINE HYDROCHLORIDE  

Adults: 25 mg IM initially; if no hypotension occurs, then 25 to 50 mg IM every 3 to 4 hours as needed until vomiting stops (maximum total dose 30 mg)

Pediatrics (6 to 11 years): 0.5 mg/kg IM every 6 to 8 hours (maximum daily dose 40 to 75 mg, depending on age)

 

Non-Procedural Therapy  

 

Migraine  

* Risk Factor Modification

* Self-Massage

* Progressive Relaxation

* Decreased Environmental Stimulation