Episode 201: Migraines

We discuss migraines with one of the authorities in the field.
Hosts:
Benjamin Friedman, MD of Montefiore
Brian Gilberti, MD



https://media.blubrry.com/coreem/content.blubrry.com/coreem/Migraines.mp3



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Tags: Neurology





Show Notes
Initial Approach to Diagnosing Migraines:

* Differentiating between primary headaches (migraine, tension-type, cluster) and secondary causes (e.g., subarachnoid hemorrhage).
* The importance of patient history and reevaluation after initial treatment.
* Recognizing the unique presentation of cluster headaches and their management implications.

Effective Acute Migraine Treatments:

* First-line treatments including anti-dopaminergic medications like metoclopramide (Reglan) and prochlorperazine (Compazine), and parenteral NSAIDs like ketorolac (Toradol).
* The limited role of triptans in the ED due to side effects and less efficacy compared to anti-dopaminergics.
* The use of nerve blocks (greater occipital nerve block and sphenopalatine ganglion block) as effective treatments without systemic side effects.

Treatments to Avoid or Use with Caution:

* Diphenhydramine (Benadryl): Studies show it does not prevent akathisia from anti-dopaminergics nor improve migraine outcomes.
* IV Fluids: Routine use is not supported unless the patient shows signs of dehydration.
* Magnesium: Conflicting evidence with some studies showing no benefit or even harm.

Managing Refractory Migraines:

* Second-line treatments including additional doses of metoclopramide combined with NSAIDs or dihydroergotamine (DHE).
* Considering opioids as a last resort when other treatments fail.
* The potential use of newer medications like lasmiditan and CGRP antagonists.

Preventing Recurrence of Migraines:

* Administering a single dose of dexamethasone (4 mg IV) to reduce the risk of headache recurrence after discharge.
* Prescribing NSAIDs or triptans upon discharge for outpatient management.
* Recognizing and addressing chronic migraine, and initiating preventive therapies like propranolol when appropriate.

Key Takeaways

* Differentiate Primary from Secondary Headaches and Reassess After Treatment:

* Use patient history and reevaluation post-treatment to distinguish migraines from more serious conditions, reducing unnecessary imaging and procedures.


* First-Line Treatments Are Effective:

* Anti-dopaminergic medications and NSAIDs are the mainstay of acute migraine treatment in the ED.
* Reserve opioids for cases unresponsive to multiple lines of treatment.


* Avoid Unnecessary Interventions:

* Diphenhydramine and routine IV fluids do not have proven benefits and can be excluded to streamline care.


* Utilize Nerve Blocks for Refractory Cases:

* Greater occipital nerve blocks and sphenopalatine ganglion blocks are ...