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
- Migraine - developed by the ECI