What is the recommended workup and treatment for a migraine headache?

Workup and Treatment for Migraine Headache

The recommended workup for migraine headache includes a detailed history and physical examination with neuroimaging only indicated for patients with abnormal neurologic findings or atypical features, while treatment should follow a stepped approach starting with NSAIDs for mild to moderate migraines and triptans for moderate to severe migraines.

Diagnostic Workup

History Taking

• Focus on identifying specific characteristics:
  • Pain location, quality, and intensity
  • Duration of headaches
  • Associated symptoms (nausea, vomiting, photophobia, phonophobia)
  • Triggers (foods, stress, hormonal changes)
  • Response to previous treatments
  • Family history of headaches
  • Pattern of headaches (frequency, timing)

Physical and Neurological Examination

• Complete neurological examination to identify any abnormalities
• Vital signs including blood pressure
• Head and neck examination

Neuroimaging Guidelines

• Neuroimaging (CT or MRI) is recommended for patients with:

  • Unexplained abnormal findings on neurological examination (Grade B) 1
  • Atypical headache features that don't fulfill the definition of migraine (Grade C) 1
  • Headache worsened by Valsalva maneuver
  • Headache that awakens the patient from sleep
  • New-onset headache in older patients
  • Progressively worsening headache 1

• Neuroimaging is not usually warranted in patients with:

  • Migraine and normal findings on neurological examination (Grade B) 1
  • Typical migraine features and no red flags 1, 2

The American College of Neurology emphasizes that MRI may be more sensitive than CT in identifying clinically insignificant abnormalities, but may not be more sensitive than CT in identifying clinically significant pathology 1.

Treatment Approach

Acute Treatment for Mild to Moderate Migraines

1. First-line: NSAIDs

   • Ibuprofen 400-800 mg
   • Naproxen sodium 275-550 mg
   • Aspirin 900-1000 mg 2, 3

2. For adolescents with inadequate response to NSAIDs:

   • Consider sumatriptan/naproxen oral, zolmitriptan nasal, sumatriptan nasal, rizatriptan ODT, or almotriptan oral 1

Acute Treatment for Moderate to Severe Migraines

1. First-line: Triptans

   • Sumatriptan 25-100 mg oral (shown to provide headache response in 50-62% of patients at 2 hours and 65-79% at 4 hours) 4
   • Consider non-oral triptans if nausea/vomiting present or if rapid pain escalation 2

2. Second-line (if triptans contraindicated or ineffective):

   • Prochlorperazine 10 mg IV with diphenhydramine 25 mg IV 2
   • Antiemetics (metoclopramide, prochlorperazine) which serve dual purpose as both antiemetic and antimigraine 2

3. If one triptan is ineffective:

   • Try another triptan or NSAID-triptan combination 1, 2

Important Contraindications

• Triptans: Uncontrolled hypertension, cardiovascular disease, basilar or hemiplegic migraine, recent use of ergotamine-type medications, MAOIs or other triptans within 24 hours 2
• NSAIDs: Aspirin/NSAID-induced asthma, bleeding disorders, G6PD deficiency (for aspirin) 2

Preventive Treatment

Indications for Preventive Therapy

• More than two headaches per week 1
• Frequent or disabling headaches 1
• Medication overuse 1

First-line Preventive Medications

• Beta-blockers: Propranolol (80-240 mg/day), Timolol (20-30 mg/day)
• Tricyclic antidepressants: Amitriptyline (30-150 mg/day)
• Anticonvulsants: Divalproex sodium (500-1500 mg/day), Topiramate 2

Lifestyle Modifications and Non-pharmacologic Approaches

• Maintain regular sleep schedule
• Identify and avoid triggers through headache diary
• Stress management techniques
• Regular hydration
• Consider cognitive-behavioral therapy, biofeedback, or relaxation training 2

Monitoring and Follow-up

• Assess response to treatment within 2-4 weeks of medication change
• Monitor for medication overuse headaches with frequent use of ergotamine, opiates, analgesics, or triptans 1
• Consider referral to neurologist or headache specialist if:
  • Headaches remain refractory to treatment
  • Neurological symptoms accompany headaches
  • Diagnostic uncertainty exists
  • Headaches significantly impact quality of life despite management 2

The workup and treatment of migraine headaches should follow a systematic approach based on headache characteristics and severity, with careful attention to potential red flags that may indicate secondary causes requiring neuroimaging.