What are the evaluation and treatment steps for migraines with identified red flags?

Evaluation and Treatment of Migraines with Red Flags

When red flags are identified in a migraine patient, immediate evaluation for secondary headache causes is mandatory, followed by appropriate treatment based on the underlying etiology.

Red Flags Requiring Urgent Evaluation

• Thunderclap headache: Sudden onset, severe headache reaching maximum intensity within seconds to minutes - requires immediate evaluation for subarachnoid hemorrhage 1
• Atypical aura: Symptoms that differ from typical migraine aura (gradual onset, spread over ≥5 minutes, duration 5-60 minutes) may indicate transient ischemic attack, stroke, epilepsy, or arteriovenous malformations 1
• Head trauma history: May suggest subdural hematoma requiring neuroimaging 1
• Progressive headache pattern: Worsening headache frequency or severity may indicate intracranial space-occupying lesion 1
• Positional aggravation: Headache worsened by postures or maneuvers that raise intracranial pressure suggests intracranial hypertension or hypotension 1
• Exertional triggers: Headache brought on by sneezing, coughing, or exercise may indicate intracranial space-occupying lesion 1
• Systemic symptoms: Headache associated with weight loss, memory changes, or personality changes suggests secondary headache 1
• New-onset after age 50: Late-onset headache should raise suspicion for secondary causes, including temporal arteritis 1

Physical Examination Red Flags

• Fever: Unexplained fever may indicate meningitis 1
• Neck stiffness: May indicate meningitis or subarachnoid hemorrhage 1
• Focal neurological deficits: Any focal neurological symptoms or signs suggest secondary headache 1, 2
• Altered mental status: Impaired memory, consciousness, or personality changes suggest secondary headache 1

Evaluation Algorithm for Red Flag Migraines

1. Initial assessment:

   • Complete neurological examination 2, 3
   • Vital signs with particular attention to fever and blood pressure 1

2. Neuroimaging:

   • Order based on specific red flags identified 2, 3
   • CT scan for acute presentations (thunderclap headache, trauma) 3
   • MRI for suspected intracranial masses, posterior fossa lesions 3

3. Laboratory testing:

   • Consider ESR/CRP for patients >50 years (temporal arteritis) 3
   • Complete blood count if infection suspected 3

4. Lumbar puncture:

   • Consider when meningitis or subarachnoid hemorrhage is suspected, especially with negative imaging but persistent clinical concern 3

Treatment Approach for Migraines with Red Flags

1. For confirmed secondary headaches:

   • Treatment directed at underlying cause 2
   • Neurosurgical consultation for structural lesions 3

2. For primary migraine after excluding secondary causes:

   • First-line acute treatment: NSAIDs (acetylsalicylic acid, ibuprofen, or diclofenac potassium) 1, 2
   • Second-line acute treatment: Triptans if no cardiovascular contraindications 1, 2
   • For nausea/vomiting: Add prokinetic antiemetics (metoclopramide or domperidone) 1, 2

3. Preventive treatment (if attacks occur ≥2 days/month):

   • First-line options: Beta-blockers (propranolol, metoprolol) or topiramate 1
   • Second-line options: Amitriptyline or flunarizine 1
   • Third-line options: OnabotulinumtoxinA or CGRP monoclonal antibodies 1

Special Considerations

• Cardiovascular risk: Triptans are contraindicated in patients with coronary artery disease, Prinzmetal's angina, uncontrolled hypertension, or stroke/TIA history 4
• Medication overuse: Assess for and address medication overuse headache (use of analgesics ≥15 days/month or triptans ≥10 days/month for ≥3 months) 1
• Follow-up: Evaluate treatment response within 2-3 months and regularly thereafter (every 6-12 months) 1

When to Refer to Specialist Care

• Diagnostically challenging cases 1
• Treatment-resistant migraines 1
• Complicated by significant comorbidities 1
• Presence of concerning red flags requiring neurological expertise 2
• All treatment failures after thorough review of diagnosis and management 1

Pitfalls to Avoid

• Failure to recognize red flags: Missing secondary causes can lead to delayed diagnosis of serious conditions 2
• Overuse of acute medications: Can lead to medication overuse headache 1
• Inappropriate use of triptans: Avoid in patients with cardiovascular disease or risk factors without proper evaluation 4
• Inadequate follow-up: Regular monitoring is essential to assess treatment effectiveness and adjust as needed 1