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Migraine

Introduction

  • Classically there is an aura, typically a sensory manifestation for that patient, e.g.“shimmering light”

  • Usually it is unilateral

  • Nausea is common and the patient can describe both periodicity and precipitating factors

  • Beware both the first migraine and “different” migraine (migraine sufferers can have SAH)

Assessment

  • Examination should be normal

  • Can present as hemiplegia (need to exclude red flag diagnoses; this should not be done in the ED). Diagnosis made in consultation with specialist, and after exhaustive investigations, especially in first presentation

  • Investigations are normally not required unless there are any red flags

Management

  • Rest in the quietest area available, darkened room and to avoid movement or any activity. Sleep will relieve symptoms.
  • Pain relief with soluble NSAID as early as possible (gastric stasis in migraine):
  • Aspirin soluble 600 to 900 mg orally, repeat in 4 hours if required (Avoid under 16 yrs)
  • Paracetamol soluble 1 g orally, 4-hourly, up to a maximum dose of 4 g daily
  • Antiemetic drugs may improve absorption of analgesic drugs and may also reduce migraine pain by other mechanisms that are poorly understood:
  • Metoclopramide 10 to 20 mg orally OR Prochlorperazine (Stemetil) 5 to 10 mg orally OR
  • Prochlorperazine (Stemetil) 12.5 mg IV or with 1000 ml Saline
  • Evidence suggests that IV prochlorperazine (Stemetil) is a safer option than IV chlorpromazine (Largactil) for migraines (due to its lower potential to cause refractory hypotension).
  • If the patient has been treated with an NSAID or simple analgesic and there is no improvement after 1 to 2 hours, or if this treatment has failed in previous attacks, then a triptan at the lower recommended dose can be used.
  • Sumatriptan 50 to 100 mg orally, up to 300 mg in any 24-hour period
  • If the lower dose of the triptan is tolerated but ineffective, the higher dose can be used in subsequent attacks.
  • Patients with vascular or coronary artery disease or uncontrolled hypertension should not use a triptan.
  • Patients with risk of serotonin toxicity due to other drugs which raise serotonin should not use a triptan.
  • Avoid opiates, usually worsen nausea and drowsiness

Disposition

Patients often have a brief sleep with chlorprpomazine, discharge if and when:

  • Pain is manageable for the patient

  • No postural drop

  • Vital signs normal

  • No Red Flags!

Patient Factsheet

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