Core EM - Emergency Medicine Podcast

Core EM - Emergency Medicine Podcast


Episode 201: Migraines

October 01, 2024





We discuss migraines with one of the authorities in the field.


Hosts:

Benjamin Friedman, MD of Montefiore

Brian Gilberti, MD





https://media.blubrry.com/coreem/content.blubrry.com/coreem/Migraines.mp3



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Tags: Neurology





Show Notes

Initial Approach to Diagnosing Migraines:



  • Differentiating between primary headaches (migraine, tension-type, cluster) and secondary causes (e.g., subarachnoid hemorrhage).
  • The importance of patient history and reevaluation after initial treatment.
  • Recognizing the unique presentation of cluster headaches and their management implications.

Effective Acute Migraine Treatments:



  • First-line treatments including anti-dopaminergic medications like metoclopramide (Reglan) and prochlorperazine (Compazine), and parenteral NSAIDs like ketorolac (Toradol).
  • The limited role of triptans in the ED due to side effects and less efficacy compared to anti-dopaminergics.
  • The use of nerve blocks (greater occipital nerve block and sphenopalatine ganglion block) as effective treatments without systemic side effects.

Treatments to Avoid or Use with Caution:



  • Diphenhydramine (Benadryl): Studies show it does not prevent akathisia from anti-dopaminergics nor improve migraine outcomes.
  • IV Fluids: Routine use is not supported unless the patient shows signs of dehydration.
  • Magnesium: Conflicting evidence with some studies showing no benefit or even harm.

Managing Refractory Migraines:



  • Second-line treatments including additional doses of metoclopramide combined with NSAIDs or dihydroergotamine (DHE).
  • Considering opioids as a last resort when other treatments fail.
  • The potential use of newer medications like lasmiditan and CGRP antagonists.

Preventing Recurrence of Migraines:



  • Administering a single dose of dexamethasone (4 mg IV) to reduce the risk of headache recurrence after discharge.
  • Prescribing NSAIDs or triptans upon discharge for outpatient management.
  • Recognizing and addressing chronic migraine, and initiating preventive therapies like propranolol when appropriate.

Key Takeaways



  • Differentiate Primary from Secondary Headaches and Reassess After Treatment:

    • Use patient history and reevaluation post-treatment to distinguish migraines from more serious conditions, reducing unnecessary imaging and procedures.


  • First-Line Treatments Are Effective:

    • Anti-dopaminergic medications and NSAIDs are the mainstay of acute migraine treatment in the ED.
    • Reserve opioids for cases unresponsive to multiple lines of treatment.


  • Avoid Unnecessary Interventions:

    • Diphenhydramine and routine IV fluids do not have proven benefits and can be excluded to streamline care.


  • Utilize Nerve Blocks for Refractory Cases:

    • Greater occipital nerve blocks and sphenopalatine ganglion blocks are effective alternatives for patients not responding to medication.


  • Prevent Recurrence with Dexamethasone and Outpatient Planning:

    • A single IV dose of dexamethasone can help prevent recurrence.
    • Provide prescriptions and consider preventive therapies to reduce future ED visits.






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