History

Fact Explanation
Headache Moderate to severe, unilateral headache is the characterized symptom which is usually throbbing in nature and worsening with routine activity. Usually the duration of headache is 4-72 hours.[1,2]
Aura It is important to know whether there is a history of characteristic aura before the onset of pain or not. Usually the aura consists of visual distortions, including scotomas, loss of vision, speech disturbances, pins and needles.[1,2]
Nausea and vomiting Usually associated with acute migraine events.[1,2]
Photophobia and phonophobia Commonly found symptom in majority of patients.[1,2]
Vertigo Also known to associated with migraine.[1,2]
Mood or behavior changes Commonly found as a prodromal symptom which signals the commencement of an acute migraine episode.[1,2]
Food cravings, heightened sensory perceptions These symptoms also found as prodromal symptoms.[1]
Past personal history or family history of migraine Presence of personal or family history of migraine will help diagnosing migraine attack.[1,2]
History of triggering event Hormonal changes (menstrual cycle), some foods, light, smell sensory stimuli, missing meals, relief of tension after stressful events, exercise can trigger development of acute attack of migraine.[1]
References
  1. AUKERMAN G, KNUTSON D, MISER WF, DEPARTMENT OF FAMILY MEDICINE, OHIO STATE UNIVERSITY COLLEGE OF MEDICINE AND PUBLIC HEALTH, COLUMBUS, OHIO. Management of the acute migraine headache. Am Fam Physician [online] 2002 Dec 1, 66(11):2123-30 [viewed 03 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/12484694
  2. GILMORE B, MICHAEL M. Treatment of acute migraine headache. Am Fam Physician [online] 2011 Feb 1, 83(3):271-80 [viewed 04 June 2014] Available from: http://www.aafp.org/afp/2011/0201/p271.html

Examination

Fact Explanation
Completely normal findings in neurological examination Complete neurological examination including the level of consciousness should be done to exclude secondary life threatening causes of headache. Should look for focal neurological signs, cranial nerve palsies, deep tendon reflexes, power of muscle groups, coordination and gait. Absence of findings in clinical neurological examination favors the diagnosis of migraine.[1,2]
Blood pressure Should be measured to rule out severe hypertension as a cause for headache.[1,2]
Ophthalmological examination To exclude acute glaucoma, eye pressure should be measured. Should look for papilledema using a ophthalmoscope, which is a sign of increased intracranial pressure.[1,2]
Kernig's sign and Brudzinski's sign These signs may be positive in meningitis. This is an important negative finding in excluding differentials. [1]
References
  1. HOLLE D., OBERMANN M.. The role of neuroimaging in the diagnosis of headache disorders. Therapeutic Advances in Neurological Disorders [online] December, 6(6):369-374 [viewed 04 June 2014] Available from: doi:10.1177/1756285613489765
  2. AUKERMAN G, KNUTSON D, MISER WF, DEPARTMENT OF FAMILY MEDICINE, OHIO STATE UNIVERSITY COLLEGE OF MEDICINE AND PUBLIC HEALTH, COLUMBUS, OHIO. Management of the acute migraine headache. Am Fam Physician [online] 2002 Dec 1, 66(11):2123-30 [viewed 03 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/12484694

Differential Diagnoses

Fact Explanation
Tension type headache This is typically a mild to moderate, pressing, tightening type, bilateral headache which is non pulsatile. It doesn't aggravate with routine activity, no associated nausea or vomiting like in migraine but patients may complain anorexia. Also there is no photophobia and phonophobia.[1,2,3]
Cluster headache Consider in patients with severe unilateral, bilateral, supraorbital, or temporal headache lasting 15-180 minutes if left untreated, with features such as lacrimation, nasal congestion, rhinorrhea, facial sweating, ptosis, miosis, eye lid swelling on the same side as the pain.[1,2,3]
Subarachnoid hemorrhage Patients will have risk factors such as hypertension and will describe as the worst headache ever they had.[1,2,3]
Brain tumor Though it is rare, can give rise to similar symptoms. Suspect patients who complain pain that disturbs sleep, occurs immediately upon awakening, aggravated with coughing and sneezing.[1,2,3]
Intra cranial infection - meningitis, encephalitis Patients will have high fever, neck stiffness in addition to headache in meningitis. In encephalitis patients may develop neurologic abnormalities, confusion, altered level of consciousness.[1,2,3]
Giant cell arteritis Commonly found in elderly (over 50 years). Pain will be associated with local tenderness in the region of the temporal artery.[1,2,3]
Post concussion headache Suspect in patients with a history of head trauma.[1,2,3]
Acute glucoma Important to exclude as it is an emergency. Patient will complain blurred vision with a red eye, nausea, vomiting, and seeing halos around lights in addition to the headache. Intraocular pressure will be high. [3]
Acute severe hypertension Blood pressure will be elevated markedly (systolic >210 mmHg or diastolic >120 mmHg). Patient may have confusion or irritability.[3]
References
  1. HOLLE D., OBERMANN M.. The role of neuroimaging in the diagnosis of headache disorders. Therapeutic Advances in Neurological Disorders [online] December, 6(6):369-374 [viewed 04 June 2014] Available from: doi:10.1177/1756285613489765
  2. AUKERMAN G, KNUTSON D, MISER WF, DEPARTMENT OF FAMILY MEDICINE, OHIO STATE UNIVERSITY COLLEGE OF MEDICINE AND PUBLIC HEALTH, COLUMBUS, OHIO. Management of the acute migraine headache. Am Fam Physician [online] 2002 Dec 1, 66(11):2123-30 [viewed 03 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/12484694
  3. GILMORE B, MICHAEL M. Treatment of acute migraine headache. Am Fam Physician [online] 2011 Feb 1, 83(3):271-80 [viewed 04 June 2014] Available from: http://www.aafp.org/afp/2011/0201/p271.html

Investigations - for Diagnosis

Fact Explanation
Neuro imaging - Computer tomography or magnetic resonence imaging of brain Should not be done routinely. Recommended for patients with migraine who have atypical headache patterns such as rapidly increasing frequency of headache, a headache that awakens the patient from sleep, persistent headache following head trauma, a history of poor coordination or focal neurological signs or symptoms.[1,3]
Electroencephalograpy Not done routinely, but useful in assessing patients who have associated symptoms suggestive of a seizure disorder, atypical migrainous aura, or episodic loss of consciousness.[1]
Lumbar puncture Should be done only suspecting meningitis or subarachnoid hemorrhage.[2]
References
  1. HOLLE D., OBERMANN M.. The role of neuroimaging in the diagnosis of headache disorders. Therapeutic Advances in Neurological Disorders [online] December, 6(6):369-374 [viewed 04 June 2014] Available from: doi:10.1177/1756285613489765
  2. AUKERMAN G, KNUTSON D, MISER WF, DEPARTMENT OF FAMILY MEDICINE, OHIO STATE UNIVERSITY COLLEGE OF MEDICINE AND PUBLIC HEALTH, COLUMBUS, OHIO. Management of the acute migraine headache. Am Fam Physician [online] 2002 Dec 1, 66(11):2123-30 [viewed 03 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/12484694

Management - General Measures

Fact Explanation
Patient and family education It is important to educate patients and their families when they are out of danger from the acute event and also to highlight the value of self-participation in the management of migraines.[1]
Adjunctive therapy - Metoclopramide, Prochlorperazine Adjunctive therapy is used to treat the associated symptoms of migraine and provide synergistic analgesia. While metoclopramide (Reglan) is sometimes recommended as a single agent in the treatment of migraine pain, its main use is for treating accompanying nausea and improving gastric motility, which may be impaired during migraine attacks. Prochlorperazine (Compazine) can effectively relieve headache pain. Caffeine and sleep are also recommend as an adjunctive therapy.[1,2]
Sedatives Sedatives such as the barbiturates have been used to induce sleep in patients with migraine. However, with the advent of effective nonsedating agents and migraine-specific therapy, sedatives are no longer widely used in migraine therapy.[1]
Steroids and intra-nasal lidocaine Steroid therapy, intravenous dexamethasone may be the treatment of choice for patients with status migrainosus, known to reduce recurrences but there are no good evidence to prove its efficacy in the treatment of the acute migraine attack. Intranasal lidocaine (Xylocaine) has a rapid onset of action and may be useful as a measure to control symptoms rapidly until the action of other drugs take place.[1,2]
References
  1. AUKERMAN G, KNUTSON D, MISER WF, DEPARTMENT OF FAMILY MEDICINE, OHIO STATE UNIVERSITY COLLEGE OF MEDICINE AND PUBLIC HEALTH, COLUMBUS, OHIO. Management of the acute migraine headache. Am Fam Physician [online] 2002 Dec 1, 66(11):2123-30 [viewed 03 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/12484694
  2. GILMORE B, MICHAEL M. Treatment of acute migraine headache. Am Fam Physician [online] 2011 Feb 1, 83(3):271-80 [viewed 04 June 2014] Available from: http://www.aafp.org/afp/2011/0201/p271.html

Management - Specific Treatments

Fact Explanation
Out patient management or hospitalization Generally acute migraine event can be treated as an out patient basis, but a migraine attack that lasts for more than 72 hours which is called status migrainosus, requires hospital inward treatment to relieve the pain and treat dehydration from vomiting.[1,2]
Acute pain management Available migraine-specific drugs are triptans such as sumatriptan, naratriptan, ergotamine and its derivatives or combined drug therapy (eg: aspirin plus acetaminophen plus caffeine). Non steroidal anti inflmmatory drugs such as ibuprofen, naprexon can be given for mild to moderate pain as a non specific therapy. If patient is having nausea or vomiting, rectal, nasal, subcutaneous or intravenous routes can be used to administer drugs. A self-administered rescue medication can be used in selected patients. Note: Opiates and butalbital-containing analgesics should be avoided.[1,2]
Ergotamine (5-hydroxytryptamine (5-HT1) nonselective agonist) and its derivatives Ergotamine is the standard therapy to halt acute migraine headache and its effectiveness depends on its administration at the onset of migraine pain. Can be given as a nasal spray or through an injection. Note: Unwanted effects include, its ability to cause medication-overuse headaches and increase the frequency of headaches, ergot poisoning and negative effects on migraine prophylactic medications.[1,2,4]
5-HT1 receptor-specific agonists (triptans) Sumatriptan is the drug of choice as it can be administered via orally if patient is able to take, parenterally as an subcutaneous injection (Imitrex) or nasal route as a spray. Usually triptans are well tolerated. Contraindicated in patients with ischemic vascular conditions, vasospastic coronary disease, uncontrolled hypertension, or other significant cardiovascular disease.[1,2,4]
Nonpharmacologic treatment Patient specific triggers should be avoided as much as possible as the first step in the nonpharmacological management. Other commonly used methods, effective in preventing migraine are relaxation training with or without thermal biofeedback, electromyographic biofeedback, and cognitive-behavioral therapy. There are some other therapies, such as acupuncture, hypnosis, transcutaneous electrical nerve stimulation, cervical manipulation, occlusal adjustment, and hyperbaric oxygen.[1,3,5]
Prophylactic measures Consider in patients having more than two headaches per week. These pharmacological agents may not completely prevent migraines, but they may reduce the number or severity of attacks that can turn into status migrainosus. These medications include: Pizotifen, Beta-blockers, Calcium channel blockers, Antidepressants such as tricyclics and monoamine oxidase inhibitors, Anticonvulsants such as divalproex sodium and sodium valproate, Botox, Natural therapies such as magnesium.[1,3,6]
References
  1. AUKERMAN G, KNUTSON D, MISER WF, DEPARTMENT OF FAMILY MEDICINE, OHIO STATE UNIVERSITY COLLEGE OF MEDICINE AND PUBLIC HEALTH, COLUMBUS, OHIO. Management of the acute migraine headache. Am Fam Physician [online] 2002 Dec 1, 66(11):2123-30 [viewed 03 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/12484694
  2. GILMORE B, MICHAEL M. Treatment of acute migraine headache. Am Fam Physician [online] 2011 Feb 1, 83(3):271-80 [viewed 04 June 2014] Available from: http://www.aafp.org/afp/2011/0201/p271.html
  3. ESTEMALIK EMAD, TEPPER . Preventive treatment in migraine and the new US guidelines. NDT [online] 2013 May [viewed 04 June 2014] Available from: doi:10.2147/NDT.S33769
  4. LOGEMANN CD, RANKIN LM. Newer intranasal migraine medications. Am Fam Physician [online] 2000 Jan 1, 61(1):180-6 [viewed 05 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/10643958
  5. GUIRGUIS-BLAKE J. Effectiveness of acupuncture for migraine prophylaxis. Am Fam Physician [online] 2010 Jan 1, 81(1):29 [viewed 05 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/20052960
  6. MODI S, LOWDER DM. Medications for migraine prophylaxis. Am Fam Physician [online] 2006 Jan 1, 73(1):72-8 [viewed 05 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/16417067