← Diagnosis and Management Guides
Migraine Headache
Key considerations: Subarachnoid hemorrhage, Meningitis, Cerebral venous thrombosis
Cannot miss
- Subarachnoid hemorrhage
- Meningitis
- Cerebral venous thrombosis
- Idiopathic intracranial hypertension
Likely diagnoses
- Migraine without aura
- Migraine with aura
- Tension headache
- Medication overuse headache
Red flags
- Thunderclap onset
- Worst headache of life
- Fever with headache
- New neuro deficits
- Age >50 new headache
- Papilledema
Workup
- history: SNOOP criteria, aura, frequency, triggers, medication overuse; exam: Fundoscopic exam, neurologic exam, neck stiffness; labs: Generally not needed unless secondary cause suspected; imaging: CT/MRI if red flags present; bedside: Visual acuity if visual symptoms
Management
- immediate: Migraine cocktail: metoclopramide 10mg IV + ketorolac 30mg IV + diphenhydramine 25mg IV; IV fluids; general: Triptans for moderate-severe (sumatriptan 6mg SC or 100mg PO); Preventive therapy if ≥4 headache days/month: topiramate, propranolol, amitriptyline, or CGRP antagonist
Disposition
- admit: Status migrainosus unresponsive to ED treatment, concern for secondary cause; discharge: After symptom relief with headache diary and follow-up plan; consults: Neurology/headache specialist for refractory or frequent migraines
Clinical pearls
- Medication overuse headache: suspect if using triptans >10 days/month or analgesics >15 days/month
- CT head is rarely indicated for classic migraine without red flags
Source and review
- AHS Migraine Guidelines 2021. Last reviewed: 2024-11-01