What imaging studies and treatments are recommended for worsening migraines?

From the Guidelines

For worsening migraines, imaging studies are generally recommended only when there are concerning features such as sudden onset of severe headaches, neurological deficits, or changes in headache pattern, and MRI is the preferred imaging modality. In these cases, MRI provides better visualization of brain tissue and can detect subtle abnormalities, such as signs of increased intracranial pressure, tumors, or pseudotumor cerebri syndrome (PTCS) 1.

Imaging Recommendations

• MRI is the imaging modality of choice for detecting signs of increased intracranial pressure, tumors, or PTCS, and should be performed with and without contrast to detect secondary signs of increased intracranial pressure 1.
• Noncontrast MRI scan of the brain, including a sagittal T2-weighted sequence of the cranio-cervical junction, is recommended for suspected Chiari I deformity 1.
• MRV is indicated in patients with possible venous sinus abnormalities, such as those with suspected PTCS, and can help detect venous outflow obstruction 1.

Treatment Options

• Acute medications like NSAIDs (ibuprofen 400-600mg or naproxen 500-550mg), triptans (sumatriptan 50-100mg orally or 6mg subcutaneously), or combination analgesics (acetaminophen/aspirin/caffeine) are commonly used for treatment 1.
• For prevention, first-line options include propranolol (80-240mg daily), topiramate (50-200mg daily), amitriptyline (10-150mg nightly), or valproate (500-1500mg daily), typically continued for 3-6 months before reassessment 1.
• Newer CGRP antagonists like erenumab (70-140mg monthly) or fremanezumab (225mg monthly) are effective alternatives for prevention 1.
• Non-pharmacological approaches, such as trigger avoidance, stress management, regular sleep patterns, and adequate hydration, are essential components of migraine management 1.
• Botulinum toxin injections (155-195 units every 12 weeks) may be considered for chronic migraines 1.

Clinical Considerations

• The use of a headache diary may help determine treatment efficacy, identify analgesic overuse, and follow up on migraine progression 1.
• Certain behavioral interventions, such as cognitive behavioral therapy, relaxation training, or mindfulness-based treatment, may decrease the frequency of migraine headaches and improve migraine-related disability 1.
• Prescribing less costly recommended medications and considering the patient's economic circumstances and personal preferences are important factors in prioritizing different classes of migraine prevention treatments 1.

From the Research

Imaging Studies for Worsening Migraines

• Computed Tomography (CT) scans are commonly used to evaluate patients with acute severe headache, including those with worsening migraines 2, 3.
• Noncontrast head CT (NCCT) is recommended for patients with sudden severe headache, also known as "worst headache of life" or "thunderclap headache" 2.
• However, the value of NCCT scanning in patients with known migraine histories and no other red flags is questionable, as it may not yield critical findings 2.
• CT Angiography (CTA) may be used to evaluate patients with acute severe headache, normal neurological examination, and normal NCCT, but its diagnostic yield is low 3.

Treatment and Diagnosis

• Sumatriptan administration in patients with unrecognized subarachnoid haemorrhage (SAH) may induce symptomatic cerebral vasospasm with potentially dangerous consequences 4.
• Intracranial hemorrhage complicating acute stroke is a rare occurrence, and the most common type of intracranial hemorrhage is intraparenchymal hemorrhage 5.
• The use of imaging studies, such as CT and MRI, plays an important role in differentiating between primary and secondary headache disorders 6.
• Emerging imaging techniques, such as functional MRI, positron emission tomography (PET) scans, and voxel-based morphometry (VBM), may also be useful in evaluating patients with headache 6.

Recommendations

• Patients with worsening migraines and no other red flags may not require immediate imaging studies, but rather a thorough clinical evaluation 2.
• CT scans, including NCCT and CTA, may be useful in evaluating patients with acute severe headache, but their use should be judicious and based on individual patient characteristics 2, 3.
• Further research is needed to determine the cost-effectiveness and therapeutic consequences of imaging studies in patients with worsening migraines 3.