What to do for a nosebleed (epistaxis) after a migraine?

Management of Nosebleed After Migraine

For a nosebleed occurring after a migraine, sit with your head slightly forward and pinch the lower third of your nose firmly for 10-15 minutes continuously without checking if the bleeding has stopped. 1

First-Line Management

• Sit upright with your head tilted slightly forward to prevent blood from entering your airway or stomach 1
• Apply firm, sustained compression to the lower third (soft part) of the nose for 10-15 minutes continuously 1
• Breathe through your mouth and spit out any blood rather than swallowing it 1, 2
• Do not tilt your head backward, as this can cause blood to flow into the throat 1

If Bleeding Persists

• If bleeding continues after 15 minutes of compression, seek medical attention 1
• A healthcare provider may use a topical vasoconstrictor such as oxymetazoline or phenylephrine nasal spray to help control bleeding 1, 2, 3
  • These medications can resolve 65-75% of nosebleeds when applied correctly 3
• For patients with identified bleeding sites, nasal cautery may be performed after proper anesthetization 1, 4

Prevention of Recurrent Nosebleeds

• Apply moisturizing agents such as petroleum jelly or saline gel to the nasal mucosa to prevent recurrence 2, 4
• Use saline nasal sprays regularly to keep the nasal mucosa moist 2, 5
• Consider using a humidifier, especially in dry environments 2, 4
• Avoid digital trauma (nose picking) and vigorous nose blowing 1

Special Considerations

• Although rare, nosebleeds can occur during or after migraine attacks (reported in about 1.1% of children with migraines) 6
• If you are taking anticoagulant or antiplatelet medications, it is reasonable to consult a healthcare professional even if bleeding has stopped 1, 2
• For patients with recurrent nosebleeds who are on anticoagulants, nasal saline gel has been shown to be effective in 93.2% of cases when applied at the first sign of bleeding 5

When to Seek Medical Attention

• If bleeding does not stop after 15 minutes of continuous pressure 1
• If you become lightheaded or dizzy from blood loss 1
• If bleeding is severe (duration >30 minutes over a 24-hour period) 1
• If you have frequent recurrent episodes of nosebleeds 4
• If you are taking anticoagulant medications and experience significant bleeding 1, 2

Advanced Treatment Options

• For persistent bleeding, healthcare providers may use nasal packing 1
• Resorbable packing materials are recommended for patients on anticoagulants or with bleeding disorders 1, 2
• Tranexamic acid (oral or topical) may reduce the risk of re-bleeding compared to placebo, with the risk reducing from 67% to 47% 7

Common Errors to Avoid

• Insufficient compression time - compression should be maintained for at least 10-15 minutes without checking if bleeding has stopped 1, 2
• Incorrect head position - many healthcare providers incorrectly advise tilting the head backward 8
• Incorrect compression site - compression should be applied to the lower third of the nose, not the nasal bridge 1, 8