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1.08 Migraine Headache


Presentation

The patient comes to the ED with a steady, severe, pain in the left or right side of the head, following ophthalmic or neurologic symptoms which resolved as the headache developed. Scintillating castellated scotomata in the visual field corresponding to the side of the subsequent headache are the classic aura, but transient weakness, vertigo, or ataxia are more likely to bring patients to the ED. Unlike other headaches, migraines are especially likely to awaken one in the morning. There may be a family or personal history of similar headaches as well.

What to do:

What not to do:

Discussion

Even more characteristic of migraine than the aura is the unilateral pain ("migraine" is a corruption of "hemicranium"). The pathophysiology is probably unilateral cerebral vasospasm (producing the neurological symptoms of the aura) followed by vasodilation (producing the headache). Neurologic symptoms may persist into the headache phase, but the longer they persist, the less likely they are due to the migraine. Cluster headaches, probably also of vascular origin, are characterized by lacrimation, rhinorrhea, and clustering in time, but the treatment of an attack is usually the same as for migraines. Acute migraine headaches are self-limited and respond well to placebos, so many therapies are effective. Medications for acute migraine pass in and out of style, and the above represent popular regimens at the time of writing. Ergotamines, phenothiazines and serotinin inhibitors may all work by cerebral vasoconstriction. One should be cautious in the use of ergot or serotonin agonists in any patient who has angina or focal weakness or sensory deficits. It is possible to precipitate an ischemic infarct of the brain or heart in such patients by using preparations which act by causing vasoconstriction. Patients with aneurysms or A-V malformations can present clinically as migraine patients. If there is something different about the severity or nature of this headache, one must think of the possibility of a subarachnoid hemorrhage. Headaches that are always on the same side and in the same location are very suspicious for an underlying structural lesion (e.g., aneurysm, AV malformation). Many patients seeking narcotics have learned that faking a migraine headache is even easier than faking a ureteral stone, but they usually do not follow through the typical course of falling asleep after a shot of and waking up a few hours later with pain relieved. It is a good policy to limit narcotics to one or two shots for migraine headaches, and not prescribe oral narcotics from the ED.

References:


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from Buttaravoli & Stair: COMMON SIMPLE EMERGENCIES
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Craig Feied, MD
Mark Smith, MD
Jon Handler, MD
Michael Gillam, MD