Migraine Headache: Guidelines Knowledge Check

Andrea Eberly, MD, MS, FAAEMEmergency Medicine, Family Medicine, Guideline Knowledge Check, Nurse Practitioner

migraine headache guidelines

Migraine Headache

Clinical Guideline Knowledge Check

Let's look at the current management of migraine headache guidelines. The 2017/2019 ACEP Guidance on Headaches addresses emergency department management of migraine (2017 expert summary) and severe headaches (2019 guideline). What is recommended regarding imaging patients who present with acute migraines that are different from their “usual” migraines?

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Today’s Guideline Knowledge Check question comes from the desk of Med-Challenger Emergency Medicine Editor-in-Chief, Andrea Eberly, MD, FAAEM.

Are you following the most current guidelines for management of migraine headaches?

“Not My Usual” Migraine:

A 27-year-old, healthy female with a history of migraines presents to the emergency department with an unusually severe migraine that is somewhat different from her usual attacks.

The onset was gradual (as usual) while driving her car in bright sunlight without sunglasses. However, this episode began with less visual auras than usual, and now is more severe and prolonged, and is located somewhat more centrally than her usually left-sided migraines.

She denies loss of consciousness, but has vomited once, which is also unusual for her migraines that normally present with nausea, but not vomiting. The headache began one hour ago and currently is at maximum intensity and “the worst ever”.

Her vital signs are normal, incl. no fever, and on exam, no neurological deficits, neck stiffness or pain with flexion is noted. Her mental status is intact and she denies any recent head trauma.

Two years ago, a magnetic resonance imaging study of the head without contrast was normal.

What do the 2019 headache guidelines published by the American College of Emergency Physicians (ACEP), in combination with their 2017 expert review on migraines, recommend with regards to imaging studies for the above patient?

Answer Options:

The patient should receive a magnetic resonance imaging study with angiography (MRA) to look for possibly missed vessel pathology..

The patient should receive a CT scan with contrast to exclude a subarachnoid bleed.

The patient should receive a CT scan or MRI with contrast to exclude a subarachnoid bleed; a negative scan should be followed by a lumbar puncture if concern for a bleed remains.

The patient should first be treated with a non-opioid medication by IV drip over 15 minutes, such as IV metoclopramide or IV prochlorperazine or IV droperidol +/- IV dihydroergotamine, and then reassessed.

See the Answer:

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About the Author:

Andrea Eberly, MD, FAAEM graduated from the David Geffen Medical School of Los Angeles (UCLA) and completed her residency in Emergency Medicine at the University Medical Center, Tucson, Arizona. After working as an attending physician in Tucson, she followed a recruiting call to the island of Guam, where she served in various roles, including as the director of the emergency department, the EMS Medical Director of Guam, and the Director of the 911 Call System. She has maintained her emergency medicine board certification through three cycles of American Board of Emergency Medicine Board Exams (last in 2014), all three with the help of Med-Challenger.