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Migraine - Adult - Ambulatory/Emergency Department

Migraine - Adult - Ambulatory/Emergency Department - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Clinical Practice Guidelines, Neurology


1
Migraine – Adult –
Ambulatory/Emergency Department
Clinical Practice Guideline
Note: Active Table of Contents – Click to follow link
EXECUTIVE SUMMARY ........................................................................................................... 3
SCOPE ...................................................................................................................................... 4
METHODOLOGY ...................................................................................................................... 4
DEFINITIONS ............................................................................................................................ 5
INTRODUCTION ....................................................................................................................... 5
RECOMMENDATIONS .............................................................................................................. 5
Headache Evaluation and Diagnosis ................................................................................... 5
Additional Evaluation .......................................................................................................... 8
Development of a Comprehensive Migraine Treatment Plan............................................... 8
Follow Up and Referral ......................................................................................................12
UW HEALTH IMPLEMENTATION ............................................................................................13
REFERENCES .........................................................................................................................15
APPENDIX A. EVIDENCE GRADING SCHEME(S) .................................................................18
APPENDIX B. DEVELOPMENT OF A COMPREHENSIVE TREATMENT PLAN. ...................19
APPENDIX C. ACUTE TREATMENT AT A HEALTH CARE FACILITY. ..................................20
APPENDIX D. MIGRAINE MEDICATION AND DOSAGE TABLE ...........................................21
APPENDIX E. MIGRAINE DISABILITY ASSESSMENT TEST (MIDAS) ..................................23
APPENDIX F. MIGRAINE TREATMENT OPTIMIZATION QUESTIONNAIRE (MTOQ-6) ........24
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Contact for Content:
Name: Douglas Dulli, MD, MS – Neurology
Phone Number: (608) 263-9058
Email Address: dulli@neurology.wisc.edu

Contact for Changes:
Name: Janna Lind, MSN – Center for Clinical Knowledge Management
Phone Number: (608) 890-6695
Email Address: jlind@uwhealth.org

Coordinating Team Members:
Allan Rifkin, MD – Clinical Professor, University Health Services
Nathan Rudin, MD – Pain Management
Dana Resop, MD – Emergency Medicine
Alison Miller, MD – Family Medicine
Matthew Anderson, MD – Internal Medicine
Steven Tyska, MD – Urgent Care
Nicole Mendolla, RN – Chemotherapy Services
Sara Shull, PharmD – Drug Policy Program
Carin Endres, PharmD – Drug Policy Program
Michael Ochowski, RPh – Group Health Cooperative
Megan Weimer, NP – Group Health Cooperative
Elaine Rosenblatt, NP – Unity Health Insurance
Philip Bain, MD – Internal Medicine, Dean Health System

Review Individuals/Bodies:
Ahmed Afifi, MD – Plastic Surgery

Committee Approvals/Dates:
Clinical Knowledge Management (CKM) Council (Last Periodic Review: MM/DD/YY)


Release Date: Choose a date. | Next Review Date: Choose a date. (2-3 yr. cycle)



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Executive Summary
Guideline Overview
The purpose of treating migraine is to provide relief of symptoms, reduce patients’
disability due to headache, and to reduce patient reliance on Emergency
Department/Urgent Care for headache management. This guideline has been developed
to assist in the assessment and treatment of adult patients diagnosed with migraine or
probable migraine headaches. The recommendations include abortive therapy,
preventive therapy, and lifestyle modifications. Medication overuse headache and
chronic migraine are also discussed.

Key Revisions (2016 Periodic Review)
1. Emphasized recommendations against opioid use
2. Removed basic drug information and contraindications, which can be found elsewhere
3. Eliminated use of the term “washout,” which implies a medication may be restarted in the
future, and removed detailed washout procedure
4. Added the mTOQ-6, which may be used to evaluate the effectiveness and tolerability of
current treatments

Key Practice Recommendations
1. If no warning signs and symptoms are present, the evaluation should focus on the diagnosis
of primary headache type (migraine, cluster, or tension-type) in order to determine the most
appropriate treatment plan for the patient (see Table 3, International Headache Society
(HIS) Diagnostic Criteria of Primary Headache). (UW Health Moderate quality evidence, strong
recommendation)
2. For patients with moderate to severe migraine headaches, it is recommended to use a
migraine-specific medication as initial abortive treatment.1 (UW Health GRADE Moderate
quality evidence, strong recommendation)
3. Because most patients seeking care for migraine experience moderate to severe headache,
it is reasonable to start with an initial triptan dose on the high end of the range, for example,
sumatriptan 100 mg oral or rizatriptan 10 mg, rather than starting with a low dose and
escalating to therapeutic effect.1 (UW Health GRADE Moderate quality evidence, weak/conditional
recommendation)
4. Tricyclic antidepressants, such as amitriptyline (UW Health GRADE Moderate quality evidence,
strong recommendation), or beta blockers, such as propranolol or metoprolol (UW Health
GRADE High quality evidence, strong recommendation), are recommended as first line
preventive therapy, if indicated.
5. Patients should be advised to take abortive medications no more than two days per week to
avoid development of medication overuse headache and chronification of migraine.2,3 (UW
Health GRADE Moderate quality evidence, strong recommendation) Medication overuse is a
particular concern with butalbital and opioids; do not use these medications to treat
migraine.3-6 (UW Health GRADE Strong quality evidence, strong recommendation)
6. Following treatment, patients who present to urgent care or emergency departments for
treatment of migraine should be referred to primary care or a headache specialist to be
evaluated for chronic migraine/medication overuse and initiation of preventive treatment if
indicated.7,8 (UW Health GRADE Moderate quality evidence, strong recommendation)

Companion Documents
1. Development of a Comprehensive Migraine Treatment Plan in Primary Care (Algorithm)
2. Acute Treatment for Migraine at a Health Care Facility (Algorithm)
3. Migraine Medication and Dosage Table
4. Migraine Disability Assessment Test (MIDAS)
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5. Migraine Treatment Optimization Questionnaire (mTOQ-6)

Scope
Disease/Condition(s): Migraine Headache

Clinical Specialty: Family Medicine, Internal Medicine, Pharmacy, Urgent Care, Emergency
Medicine

Intended Users: Primary Care Physicians, Advanced Practice Providers, Pharmacists,
Registered Nurses

Objective(s): To provide an evidence-based guideline to assist clinicians in the evaluation and
treatment of patients with migraine headaches.

Target Population: Nonpregnant, non-breastfeeding, adults (ages 18 years and over) with
migraine headaches. UW Health has a separate guideline for pediatric migraine management.

Interventions and Practices Considered:
1. Assessment of headache symptoms, headache frequency, degree of disability, and
effectiveness of treatment using validated assessment tools
2. Pharmacotherapy for abortive and preventive treatment
3. Factors related to lifestyle behaviors, possible triggers, and comorbid conditions

Major Outcomes Considered:
1. Relief of migraine symptoms
2. Reduction of migraine-associated disability
3. Reduction of frequency of recurrent migraines
4. Reduced patient reliance on Emergency Department/Urgent Care and non-scheduled visits
for headache management
5. Increased usage of preventive medications for frequent migraine sufferers

Methodology
Methods Used to Collect/Select the Evidence:
Electronic database searches (e.g., PUBMED) were conducted by the guideline author(s) and
workgroup members to collect evidence for review. Expert opinion and clinical experience were
also considered during discussions of the evidence.

Methods Used to Formulate the Recommendations:
The workgroup members agreed to adopt recommendations developed by external
organizations and/or arrived at a consensus through discussion of the literature and expert
experience. All recommendations endorsed or developed by the guideline workgroup were
reviewed and approved by other stakeholders or committees (as appropriate).

Methods Used to Assess the Quality of the Evidence/Strength of the Recommendations:
Recommendations developed by external organizations maintained the evidence grade
assigned within the original source document and were adopted for use at UW Health.

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Internally developed recommendations, or those adopted from external sources without an
assigned evidence grade, were evaluated by the guideline workgroup using an algorithm
adapted from the Grading of Recommendations Assessment, Development and Evaluation
(GRADE) methodology (see Figure 1 in Appendix A).

Rating Scheme for the Strength of the Evidence/Recommendations:
See Appendix A for the rating scheme(s) used within this document.

Recognition of Potential Health Care Disparities:
According to the National Health Interview Survey (NHIS), the average prevalence of severe
headache or migraine from 2005 to 2012 was 17.7% for Native Americans, 15.5% for Whites,
14.5% for Hispanics, 14.45% for African Americans, and 9.2% for Asians. As compared to
Whites, African American were less likely to utilize the health-care setting for migraine
treatments and to have been prescribed acute migraine medication. Lower rates of diagnosis in
some groups may indicate racial and ethnic disparities in access and quality of care for minority
patients. 9,10 Due to the large spectrum of the cost of medications used to treat migraine,
sensitivity should be given to socioeconomic status and coverage of medication costs.

Definitions
Primary Headache is a headache due to a headache condition itself and not caused by another
medical condition.

Secondary Headache is a headache resulting from another medical condition.

Abortive Medications are taken at the first sign of an impending migraine headache. They work
to stop the migraine process itself.11

Preventive Medications are taken daily to reduce the frequency and severity of migraine
headache.11

Introduction
Migraines affect approximately 36 million people in the United States.12 Although migraines are
treatable, missed diagnoses frequently lead to under-treatment in this population.13 Of those
diagnosed with migraine, approximately 25% are candidates for preventive therapy, yet only
13% report current daily use of a preventive agent.12 The disability, lost productivity, decreased
quality of life, and increased use of emergent and acute care associated with under-recognized
disease and missed treatment opportunities is substantial.

Recommendations
Headache Evaluation and Diagnosis
Evaluation for patients presenting with headache should include a medical history, a headache
history, and a physical exam (see Table 1, Headache Evaluation).

All patients presenting with headache, especially those presenting for the first time or with a
change in headache symptoms, should be evaluated for possible indicators of a serious
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condition that may require immediate action or further evaluation and referral (see Table 2,
Warning Signs and Symptoms). (UW Health Moderate quality evidence, strong recommendation)

Table 1: Headache Evaluation
Look for evidence of meningeal irritation, papilledema, bruits, or neurological signs, which
suggest the need for further investigation.
Physical Exam. At minimum, evaluate the following:
Vital signs, including temperature
Cardiac exam
Evidence of sinus etiology
Scalp arteries
Carotid arteries
Cervical paraspinal muscles
Cervical range of motion
Neurological evaluation, including cranial nerves, cranial vasculature, mental status, reflexes,
funduscopic exam


Table 2: Warning Signs and Symptoms
Potentially ominous headache warning signs and symptoms may indicate intracranial infection,
bleed, mass, or temporal arteritis.
Refer to appropriate emergency or specialty care provider if indicated.
Atypical headache; worst headache in patient’s life
Fever, nuchal rigidity, marked increase in blood pressure
Neurological symptoms, especially if new onset
Altered mental status
Sudden onset of severe headache
Cognitive/behavioral changes
Abnormality in neurological exam
New onset severe headache after age 40
Abrupt onset headaches triggered by (not exacerbated by) exertion, cough, sexual activity,
straining
Progressive daily headache, especially if progressing over days or weeks

If no warning signs and symptoms are present, the evaluation should focus on the diagnosis of
primary headache type (migraine, cluster, or tension-type) in order to determine the most
appropriate treatment plan for the patient (see Table 3, International Headache Society (IHS)
Diagnostic Criteria of Primary Headache).2 (UW Health Moderate quality evidence, strong
recommendation)

If no warning signs and symptoms are present and primary headache type is unclear, consider
a diagnosis of probable migraine (migraine that does not fully meet IHS criteria for a diagnosis
of migraine).2

Patients with frequent migraine headaches should be evaluated for chronic migraine (15 days
per month or more) and medication overuse (10-15 times per month for 3 months), as these
conditions often occur concomitantly and require a different treatment approach (see Table 4,
Medication Overuse Headache and Chronic Migraine).2 (UW Health Moderate quality evidence,
strong recommendation)

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In chronic migraine, many headaches are characterized by pressing/tightening quality, mild to
moderate intensity, bilateral location, no aggravation by physical activity, and absence of
vomiting, making the headaches indistinguishable from tension-type headaches. The provider
should be alert to the possibility that the presentation of frequent tension-type headaches in a
migraine sufferer may represent transformation of episodic to chronic migraine.2

Table 3: International Headache Society Diagnostic Criteria of Primary Headache
Migraine Headache2
5 or more headache attacks, each attack lasting 4-72 hours if untreated
Any 2 of the following:
ξ unilateral
ξ pulsatile
ξ moderate to severe intensity (the most important differentiation from tension headache)
ξ worse with exertion
And at least one of the following:
ξ nausea and/or vomiting
ξ photo and phonophobia
Secondary headache types not suggested or confirmed
Cluster Headache2
Severe unilateral pain in the orbit and/or surrounding areas lasting 15-180 minutes untreated
Headache is associated with at least one of the following signs on the side of the pain:
ξ conjunctival injection (reddened eyeball) lacrimation (excessive tears from the eye) nasal
congestion (stuffy nose)
ξ rhinorrhea (runny nose) facial sweating
ξ miosis (smaller pupil)
ξ ptosis (lowered upper eyelid)
ξ eyelid edema (lid becomes puffy)
Frequency of attacks: from 1 every other day to 8 per day
Restlessness; need to keep moving
Secondary headache types neither suggested nor confirmed
Tension-Type Headache2
Patients with this disorder (in the absence of other headache types) typically self-medicate,
without the advice or assistance of a care provider.
At least 2 of the following pain characteristics:
ξ pressing (non-pulsating) quality
ξ mild or moderate intensity (may inhibit, but does not prohibit activities)
ξ bilateral location
ξ no aggravation by walking stairs or similar routine physical activity
None of the following:
ξ nausea or vomiting
ξ photophobia or phonophobia
Secondary headache types not suggested or confirmed

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Table 4: Medication Overuse Headache and Chronic Migraine
Medication Overuse Headache2
Headache occurring on 15 or more days per month in a patient with a pre-existing headache
disorder
Regular overuse (10 to 15 times per month, depending on the medication) for greater than 3
months of one or more drugs that can be taken for acute and/or symptomatic treatment of
headache
Secondary headache types neither suggested nor confirmed
Chronic Migraine2
Headache occurring on 15 or more days per month for greater than 3 months
Headaches have migrainous features on at least 8 days per month
Secondary headache types neither suggested nor confirmed

Additional Evaluation
Once migraine headache has been diagnosed, evaluate severity, frequency, and disability due
to migraine headache to establish a baseline prior to initiating new therapy. The patient
questionnaire Migraine Disability Assessment Score (MIDAS) may be used for this purpose.14 A
score of 21 or greater on the MIDAS indicates severe disability and likely medication overuse
headache and/or chronic migraine.

In patients with experience using medication to treat migraine headache, determine previous
therapies used and response to treatment. The Migraine Treatment Optimization Questionnaire
(mTOQ-6) may be used to evaluate the effectiveness and tolerability of current treatment and
subjectively guide modifications to the treatment plan to better meet the treatment goals.15
Development of a Comprehensive Migraine Treatment Plan
The goals of an effective treatment plan are15,16:
ξ Migraine-free in 2 hours or less, including relief of vomiting and other associated symptoms
ξ Sustained relief of migraine for 24 hours
ξ Tolerability of medications (avoidance of adverse drug effects)
ξ Treatment of comorbid conditions
ξ Reduced dependance on treatment at urgent care centers, emergency departments, and/or
unscheduled clinic visits

An algorithm for Development of a Comprehensive Migraine Treatment Plan in the Primary
Care Setting is included in Appendix B.

An algorithm for Acute Treatment for Migraine at a Clinic, Urgent Care Center, or Emergency
Department is included in Appendix C.

See Appendix D, Migraine Medication and Dosage Table for additional information on abortive
therapies, supportive therapies including antiemetics, and preventive therapies.

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Abortive Therapy
There are several over the counter analgesics that have been shown to effectively treat the
symptoms of migraine headache, for example, acetaminophen, ibuprofen, aspirin, and
acetaminophen/aspirin/caffeine combination products.17 The majority of patients seeking care
for migraine headache, however, have moderate to severe symptoms and have already tried
over the counter treatment. Therefore, for patients with moderate to severe migraine
headaches, it is recommended to use a migraine-specific medication as initial abortive
treatment.1 (UW Health GRADE Moderate quality evidence, strong recommendation)

Triptans: Triptans have consistently been shown to be effective in the abortive treatment of
migraine and are recommended as first line therapy for home use.17 (UW Health GRADE High
quality evidence, strong recommendation) Oral triptans are most effective when taken early in an
attack. Therefore, patients should be instructed carry their medication with them at all times and
to take their medication at the first sign of an impending attack.

Because most patients seeking care for migraine experience moderate to severe headache, it is
reasonable to start with an initial triptan dose on the high end of the range, for example,
sumatriptan 100 mg oral or rizatriptan 10 mg, rather than starting with a low dose and escalating
to therapeutic effect.1 (UW Health GRADE Moderate quality evidence, weak/conditional
recommendation)

Triptans taken with naproxen sodium have been shown to be more effective than triptans alone.
Unless there are contraindications to NSAID therapy, it is recommended to advise patients to
take naproxen sodium with a triptan in the early phase of an attack.17 (UW Health GRADE High
quality evidence, weak/conditional recommendation)

There are multiple triptan medications on the market, each with unique pharmacokinetic profiles.
Some patients may find one medication to be more effective with fewer side effects than
another medication. If other triptans are poorly tolerated, consider naratriptan as it often has
milder side effects.18 (UW Health GRADE low quality evidence, weak/conditional recommendation)

Sumatriptan is available as a subcutaneous injection and may be considered for home use for
rapidly progressive, severe, or nocturnal migraine, as well as for patients with severe nausea
and vomiting who cannot tolerate oral medications. Sumatriptan subcutaneous injection is also
recommended to treat patients presenting with severe migraine at a clinic, urgent care center, or
emergency department.17 (UW Health GRADE High quality evidence, strong recommendation)

Dihydroergotamine (DHE): DHE injection is an excellent choice for the treatment of migraine
headache at a healthcare facility such as an infusion center, urgent care center, or emergency
department.17 (UW Health GRADE Moderate quality evidence, strong recommendation) DHE is
effective regardless of the duration of the headache; it does not need to be administered early in
an attack to be effective. DHE nasal spray can be considered as home treatment for triptan non-
responders but may be cost prohibitive.17 (UW Health GRADE High quality evidence,
weak/conditional recommendation) Please note DHE should not be used if a triptan has been taken
in the previous 24 hours. Triptans and DHE should also be avoided in patients with uncontrolled
hypertension or a history of any type of vascular disease.

Supportive therapies: Antiemetics can be used to treat symptoms of nausea and vomiting
and/or as a prophylactic treatment for patients who will receive DHE (nausea and vomiting is a
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potential side effect of this medication). There is also evidence that suggests dopamine receptor
antagonists (e.g., metoclopramide, prochlorperazine, haloperidol) may help abort the migraine
process itself.17,19-21 Use of an antiemetic is recommended in the treatment of migraine. (UW
Health GRADE High quality evidence, weak/conditional recommendation)

Administration of diphenhydramine may be considered, as it has antiemetic properties and may
mitigate the potential extrapyramidal side effects of dopamine-blocking antiemetics. (UW Health
GRADE Low quality evidence, weak/conditional recommendation) Evidence suggests
diphenhydramine reduces akathisia associated with prochlorperazine IV
administration; however there may be no benefit when administering diphenhydramine to
prevent akathisia resulting from low doses of IV metoclopramide.22-24

Additional abortive medications: If there has been an inadequate response to supportive
therapies and/or DHE or triptans, then consider administration of one of the following based on
individual patient factors (e.g., bleed risk, renal disease) and previous response to treatment:
ketorolac IV (UW Health GRADE Moderate quality evidence, weak/conditional recommendation),
magnesium IV (UW Health GRADE Moderate quality evidence, strong recommendation), or valproate
sodium IV (UW Health GRADE Weak quality evidence, weak/conditional recommendation).

Opioids: Opioid use for the treatment of migraine is associated with development of medication
overuse headache, the progression of episodic migraine to chronic migraine, greater headache-
related disability, more severe symptoms, and greater use of health care resources. Close to
17% of patients who take opioids for migraine headache meet criteria for probable dependance.
Opioids and barbiturates are NOT recommended for treatment of migraine, except as a last
resort in extraordinary circumstances.3-5,7,25,26 (UW Health GRADE High quality evidence, strong
recommendation) This includes butorphanol, tramadol, and the barbiturate, butalbital.

Preventive Therapy
The indications for starting preventive therapy include:
ξ Patient has 3 or more severe migraine attacks per month that fail to respond adequately to
abortive or symptomatic therapy
ξ The migraine attacks are severe enough to impair the patient’s quality of life
ξ In any patient who has more than 2 headaches/week that require pharmacologic
intervention.12

The primary goals of effective preventive therapy are to reduce migraine attack frequency,
reduce the number of migraine days, and/or reduce the severity and duration of the attacks.8
Additional goals are to improve the responsiveness to treatment of acute attacks, improve
function and reduce disability, and prevent transformation of episodic migraine to chronic
migraine.27 The underlying principle in prescribing preventive medication is to use the least
amount of medication with the fewest side effects to gain control of symptoms until the
preventive treatment can be stopped. The preventive medications are better tolerated when
started slowly and escalated to therapeutic doses. The medication should be continued for an
adequate period, usually several months, to determine effectiveness.14

Tricyclic antidepressants, such as amitriptyline (UW Health GRADE Moderate quality evidence,
strong recommendation), or beta blockers, such as propranolol or metoprolol (UW Health GRADE
High quality evidence, strong recommendation), are recommended as first line therapy.8
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Anti-epileptic medications, such as topiramate and divalproex, have been shown to be effective
and may be considered as a second line therapy.8 (UW Health GRADE High quality evidence,
weak/conditional recommendation) However, these medications are associated with a historically
high rate of adverse effects, including cognitive impairment and teratogenicity, and are not
recommended without a discussion of the risks and benefits. (UW Health GRADE High quality
evidence, weak/conditional recommendation) Women of childbearing age should use an effective
form of birth control if these medications are prescribed.

If two or more preventive medications are ineffective or poorly tolerated, consider a referral to a
headache specialist. After evaluating the patient, a headache specialist may recommend further
interventions such as onabotulinumtoxinA for chronic migraine.28,29 Refer to the UW Health
Botulinum Toxin – Adult/Pediatric – Ambulatory Guideline.

Lifestyle Behaviors and Comorbid Conditions
Multiple lifestyle, behavioral, and environmental factors are associated with migraine or
transition from episodic to chronic migraine. Patients should be advised to follow regular
patterns of sleep, exercise, mealtimes, and hydration status.30 (UW Health GRADE Moderate
quality evidence, strong recommendation) Patients should be aware of possible migraine triggers,
for example, certain foods, cigarette smoke, lighting, and other environmental factors.31

Anxiety and depression, sleep apnea, obesity, cigarette smoking, and medication overuse are
all comorbid conditions and behaviors associated with episodic or chronic migraine.32-36 It is
advised to discuss and treat these conditions as changes may improve migraine symptoms,
prevent transition to chronic migraine, or help convert a patient with chronic back to episodic
migraine. (UW Health GRADE Moderate quality evidence, strong recommendation)

Additional Therapies
There are many complimentary and alternative therapies for migraine treatment and prevention
that can be considered based on individual patient preferences and potential benefits. (UW
Health GRADE Low quality evidence, weak/conditional recommendation) Complementary techniques
such as biofeedback, relaxation training, massage, and acupuncture can be helpful for many
patients. 37-39 Nutraceuticals such as magnesium oxide, riboflavin, coenzyme Q10, and extract
of butterbur root are occasionally useful as supplemental or alternative therapy. 40,41 Evidence
supporting the effectiveness of these therapies is not robust, however they are generally safe
and well tolerated.

Migraine surgery is available at UW Health for patients who have not adequately responded to
medical treatment. There is evidence to support the effectiveness of migraine surgery; however
there is some controversy about the quality and robustness of the evidence. Patients should not
routinely be referred for migraine surgery without a careful discussion of the likelihood of
effectiveness and possible adverse effects, some of which may be permanent (e.g. temporal
hollowing).42,43 (UW Health GRADE Moderate quality evidence, weak/conditional recommendation) Not
all patients are candidates for migraine surgery, and patients should be adequately evaluated
by a neurologist or primary care doctor before being referred for a surgical evaluation.

Medication Overuse/Chronic Migraine
Medication overuse headache (MOH) is associated with the transformation from episodic to
chronic migraine and can decrease the responsiveness to both abortive and preventive
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12


medications. Overuse of any medication used to treat migraine can result in MOH, including
over the counter analgesics and triptans. Patients should be advised to take abortive
medications no more than two days per week to avoid development of medication overuse
headache and chronification of migraine.2,3 (UW Health GRADE Moderate quality evidence, strong
recommendation) Medication overuse is a particular concern with butalbital and opioids; do not
use these medications to treat migraine.3-6 (UW Health GRADE Strong quality evidence, strong
recommendation)

Chronic Migraine is the most common underlying cause of frequent presentations to urgent care
and emergency department settings, due to the very high frequency of severe migraine
headaches that accompany this condition. It is also the most prominent cause of disability
associated with headache disorders. Chronic migraine complicated by medication overuse,
especially opioids, can be especially challenging to treat in both the primary care and urgent
care/emergency department settings.25 Following treatment, patients who present to urgent
care or emergency departments for treatment of migraine should be referred to primary care or
a headache specialist to be evaluated for chronic migraine/medication overuse and initiation of
preventive treatment if indicated.7,8 (UW Health GRADE Moderate quality evidence, strong
recommendation) Initiation of preventive treatment and weaning off overused medications may
decrease usage of urgent/emergency care for migraine treatment.

There is still debate as how best to approach treatment for a patient with frequent headaches
who is overusing medication. It is a reasonable approach to start a preventive medication and
begin weaning off of the overused medication.36 (UW Health GRADE Moderate quality evidence,
weak/conditional recommendation) The preferred method for weaning a patient off an overused
medication will vary greatly based on the type and dose of medication in use and patient
specific factors and preferences. If a patient with medication overuse is not improving on
preventive medication, the patient may need to completely stop using the overused
medication(s) before effective treatment can be achieved.
Follow Up and Referral
Patients should be advised to use a headache diary to track symptoms, severity, and frequency
of headache, possible triggers, treatments used, and response to treatment.16 (UW Health
GRADE Low quality evidence, weak/conditional recommendation) A sample headache diary can be
found on uwhealth.org.

The patient should be instructed to contact the clinic for a change in headache pattern or new
symptoms, adverse effects to medications, or if medications are ineffective. If starting a new
preventive medication, consider a follow up visit in about 4-6 weeks to discuss response to
medication. (UW Health Very low quality evidence, weak/conditional recommendation)

Follow up visits may include use of the MIDAS and/or mTOQ-6 patient questionnaires to
evaluate migraine frequency, severity, disability, and effectiveness of treatment (including need
for adjustments in medication therapy).

Referral to a headache specialist should be considered for atypical headache features, a
concerning change in headache pattern, or for chronification of migraine. A referral is also
advised if there are excessive side effects or a lack of effect in at least two preventive
medications.


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13


UW Health Implementation
Potential Benefits:
ξ Increased recognition and diagnosis of migraines in the primary care setting
ξ Optimized treatment in adults with migraine headaches

Potential Harms:
ξ Adverse events associated with therapies
ξ Medication overuse headaches

Pertinent UW Health Policies & Procedures
UW Health Clinical Policy #1.2.3 Opiate Management

Patient Resources
1. Health Facts For You #5355 – Migraine Headaches
2. Health Facts For You #6764 – Migraine Headaches – Spanish Version
3. Health Facts For You #5896 – Medication Overuse Headaches
4. Health Facts For You #6765 – Medication Overuse Headaches – Spanish Version
5. Health Facts For You #6473 – Headache, Working with Your Doctor to Avoid the
Emergency Room
6. Health Facts For You #6766 – Headache, Working with Your Doctor to Avoid the
Emergency Room – Spanish Version
7. Healthwise – Migraine Headaches
8. Healthwise – Migraine Headache Triggers
9. Healthwise – Migraines: Finding and Avoiding Triggers
10. Healthwise – Headache Diary
11. Healthwise – Headaches: Should I Take Medicines to Prevent Migraines?
12. Healthwise – Headaches: Should I have imaging test to find out what’s causing my
headaches?
13. Healthwise – Ergotamines for Migraine Headaches
14. Healthwise – Antidepressants for Migraine Headaches
15. Healthwise – Seizure Medicine to Prevent Migraine Headaches
16. Healthwise – Headaches: Managing a Headache
17. Healthwise – Headaches
18. Healthwise – Headaches
19. Lexicomp – Migraine Headache Discharge Instructions

Guideline Metrics
1. Number of patients with a reason for visit of “migraine” or “headache” who received an
opioid in the clinic or a prescription for opioids during that visit
2. % of patients discharged from the emergency department with a diagnosis of migraine who
had a follow up visit arranged with PCP or headache specialist
3. % of patients on a preventive medication for migraine. Could benchmark with national data.

Implementation Plan/Clinical Tools
1. Guideline will be posted on U-Connect in a dedicated location for Clinical Practice
Guidelines.
2. Release of the guideline will be advertised in the Physician/APP Briefing newsletter.
3. Content and hyperlinks within clinical tools, documents, or Health Link related to the
guideline recommendations (such as the following) will be reviewed for consistency and
modified as appropriate.
Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2017CCKM@uwhealth.org

14



Delegation Protocols
Prescription Renewal Protocol for UW Health Pain and Headache Clinics for Medications

eConsults
eConsult to Neurology – Established Diagnosis – Headache Migraine [5386]
eConsult to Neurology – New/Changed Headache [5415]

Order Sets & Smart Sets
Headache – Specialty [3363]
Headache [80]
ED – Headache – Adult [631]
Headache – Adult – e-Visit [4912]
Headache Trigger injections [4255]
Injection – Headache [171]
Injection – Headache [3593]
Rehab Medicine – Botox [2302]

Disclaimer
Clinical practice guidelines assist clinicians by providing a framework for the evaluation and
treatment of patients. This guideline outlines the preferred approach for most patients. It is not
intended to replace a clinician’s judgment or to establish a protocol for all patients. It is
understood that some patients will not fit the clinical condition contemplated by a guideline and
that a guideline will rarely establish the only appropriate approach to a problem.

Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
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15


References
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strategies for migraine: the Disability in Strategies of Care (DISC) Study: A randomized
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4. Bigal ME, Lipton RB. Excessive opioid use and the development of chronic migraine.
Pain. 2009;142(3):179-182.
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medications and evolution from episodic to chronic migraine: a longitudinal population-
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7. Buse DC, Manack AN, Fanning KM, et al. Chronic migraine prevalence, disability, and
sociodemographic factors: results from the American Migraine Prevalence and
Prevention Study. Headache. 2012;52(10):1456-1470.
8. Silberstein SD, Holland S, Freitag F, Dodick DW, Argoff C, Ashman E. Evidence-based
guideline update: pharmacologic treatment for episodic migraine prevention in adults:
report of the Quality Standards Subcommittee of the American Academy of Neurology
and the American Headache Society. Neurology. 2012;78(17):1337-1345.
9. Loder S, Sheikh HU, Loder E. The prevalence, burden, and treatment of severe,
frequent, and migraine headaches in US minority populations: statistics from National
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ethnicities: do disparities exist? Headache. 2006;46(5):754-765.
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Migraine Disability Assessment (MIDAS) score in comparison to a diary-based measure
in a population sample of migraine sufferers. Pain. 2000;88(1):41-52.
15. Serrano D, Buse DC, Manack Adams A, Reed ML, Lipton RB. Acute treatment
optimization in episodic and chronic migraine: results of the American Migraine
Prevalence and Prevention (AMPP) Study. Headache. 2015;55(4):502-518.
16. Silberstein SD. Practice parameter: evidence-based guidelines for migraine headache
(an evidence-based review): report of the Quality Standards Subcommittee of the
American Academy of Neurology. Neurology. 2000;55(6):754-762.
17. Marmura MJ, Silberstein SD, Schwedt TJ. The acute treatment of migraine in adults: the
american headache society evidence assessment of migraine pharmacotherapies.
Headache. 2015;55(1):3-20.
18. Dulli DA. Naratriptan: an alternative for migraine. Ann Pharmacother. 1999;33(6):704-
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16


19. Gaffigan ME, Bruner DI, Wason C, Pritchard A, Frumkin K. A Randomized Controlled
Trial of Intravenous Haloperidol vs. Intravenous Metoclopramide for Acute Migraine
Therapy in the Emergency Department. J Emerg Med. 2015;49(3):326-334.
20. Kelley NE, Tepper DE. Rescue therapy for acute migraine, part 2: neuroleptics,
antihistamines, and others. Headache. 2012;52(2):292-306.
21. Eken C. Critical reappraisal of intravenous metoclopramide in migraine attack: a
systematic review and meta-analysis. Am J Emerg Med. 2015;33(3):331-337.
22. Friedman BW, Esses D, Solorzano C, et al. A randomized controlled trial of
prochlorperazine versus metoclopramide for treatment of acute migraine. Ann Emerg
Med. 2008;52(4):399-406.
23. Vinson DR. Diphenhydramine in the treatment of akathisia induced by prochlorperazine.
J Emerg Med. 2004;26(3):265-270.
24. Vinson DR, Drotts DL. Diphenhydramine for the prevention of akathisia induced by
prochlorperazine: a randomized, controlled trial. Ann Emerg Med. 2001;37(2):125-131.
25. Buse DC, Pearlman SH, Reed ML, Serrano D, Ng-Mak DS, Lipton RB. Opioid use and
dependence among persons with migraine: results of the AMPP study. Headache.
2012;52(1):18-36.
26. Franklin GM. Opioids for chronic noncancer pain: a position paper of the American
Academy of Neurology. Neurology. 2014;83(14):1277-1284.
27. Loder E, Biondi D. General principles of migraine management: the changing role of
prevention. Headache. 2005;45 Suppl 1:S33-47.
28. U.S. Food and Drug Administration. FDA approves Botox to treat chronic migraine.
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29. Aurora SK, Winner P, Freeman MC, et al. OnabotulinumtoxinA for treatment of chronic
migraine: pooled analyses of the 56-week PREEMPT clinical program. Headache.
2011;51(9):1358-1373.
30. Woldeamanuel YW, Cowan RP. The impact of regular lifestyle behavior in migraine: a
prevalence case-referent study. J Neurol. 2016;263(4):669-676.
31. Borkum JM. Migraine Triggers and Oxidative Stress: A Narrative Review and Synthesis.
Headache. 2016;56(1):12-35.
32. Seng EK, Seng CD. Understanding migraine and psychiatric comorbidity. Curr Opin
Neurol. 2016;29(3):309-313.
33. Harnod T, Wang YC, Kao CH. Association of Migraine and Sleep-Related Breathing
Disorder: A Population-Based Cohort Study. Medicine (Baltimore). 2015;94(36):e1506.
34. Ornello R, Ripa P, Pistoia F, et al. Migraine and body mass index categories: a
systematic review and meta-analysis of observational studies. J Headache Pain.
2015;16:27.
35. Qi Gan W, Estus S, Smith JH. Association Between Overall and Mentholated Cigarette
Smoking With Headache in a Nationally Representative Sample. Headache.
2016;56(3):511-518.
36. Chiang CC, Schwedt TJ, Wang SJ, Dodick DW. Treatment of medication-overuse
headache: A systematic review. Cephalalgia. 2015.
37. Linde K, Allais G, Brinkhaus B, Manheimer E, Vickers A, White AR. Acupuncture for
migraine prophylaxis. Cochrane Database Syst Rev. 2009(1):Cd001218.
38. Nestoriuc Y, Martin A. Efficacy of biofeedback for migraine: a meta-analysis. Pain.
2007;128(1-2):111-127.
39. Chaibi A, Tuchin PJ, Russell MB. Manual therapies for migraine: a systematic review. J
Headache Pain. 2011;12(2):127-133.
40. Tepper SJ. Nutraceutical and Other Modalities for the Treatment of Headache.
Continuum (Minneap Minn). 2015;21(4 Headache):1018-1031.
Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2017CCKM@uwhealth.org

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41. Sun-Edelstein C, Mauskop A. Alternative headache treatments: nutraceuticals,
behavioral and physical treatments. Headache. 2011;51(3):469-483.
42. American Headache Society. American Headache Society Urges Caution in Using Any
Surgical Intervention in Migraine Treatment. Mt Royal, NJ2012.
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surgical trial of the treatment of migraine headaches. Plast Reconstr Surg.
2009;124(2):461-468.


Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2017CCKM@uwhealth.org

18


Appendix A. Evidence Grading Scheme(s)

Figure 1. GRADE Methodology adapted by UW Health


GRADE Ranking of Evidence
High We are confident that the effect in the study reflects the actual effect.
Moderate We are quite confident that the effect in the study is close to the true effect, but it
is also possible it is substantially different.
Low The true effect may differ significantly from the estimate.
Very Low The true effect is likely to be substantially different from the estimated effect.

GRADE Ratings for Recommendations For or Against Practice
Strong The net benefit of the treatment is clear, patient values and circumstances
are unlikely to affect the decision.
Weak/conditional
Recommendation may be conditional upon patient values and
preferences, the resources available, or the setting in which the
intervention will be implemented.






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Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2017CCKM@uwhealth.org

19


Appendix B.


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20


Appendix C.
Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2017CCKM@uwhealth.org

21


Appendix D. Migraine Medication and Dosage Table
Product How supplied Dosage Ranges Generic
Available?
Abortive or Rescue Therapy
Triptans
Almotriptan 6.25, 12.5mg tab 6.25-12.5mg once, may repeat after 2 hours;
Max 25mg/24hr
Yes
Eletriptan 20, 40mg tab 20-40mg once,
may repeat after 2 hours;
Max 80mg/24hr
No
Frovatriptan 2.5mg tab 2.5mg once,
may repeat after 2 hours;
Max 7.5mg/24hr
No
Naratriptan 1, 2.5mg tab 1-2.5mg once,
may repeat after 4 hours;
Max 5mg/24hr
Yes
Rizatriptan 5, 10mg tab
5, 10mg ODT
5-10mg once,
may repeat after 2 hours;
Max 30 mg/24hr
Yes
Sumatriptan 25, 50, 100mg tablet

5, 20mg nasal spray

6mg/0.5mL, 4mg/0.5mL,
3mg/0.5mL subcutaneous
injection

6.5mg/4 hr transdermal
patch

Tab: 25-100mg once, may repeat after 2 hours;
Max 200mg/24hr

Nasal: 5-20mg once, may repeat after 2 hours;
Max 40mg/24hr

SubQ: 1-6mg once, may repeat after 1 hr;
Max 12mg/24hr

TransD: 1 patch once,
may apply second patch at least 2 hours after
activation of first;
Max 2 patches/24hr
Tab: Yes
Nasal: Yes
SubQ: Yes but not
3mg/0.5mL pen
TransD: No
Zolmitriptan 2.5, 5mg tab
2.5, 5mg ODT
2.5, 5mg nasal spray

Tab: 1.25-2.5mg once,
may repeat after 2 hours;
Max 10 mg/24hr

Nasal: 2.5 mg once, may repeat after 2 hours;
Max 10 mg/24hr
Tab: Yes
Nasal: No
Ergot Derivatives
Dihydroergotamine (DHE) 4mg/mL nasal spray
1mg/mL injection solution
IM/SQ/IV: 1mg once, may repeat at 1 hour
intervals;
Max 3mg (2mg IV) per 24hr

Nasal: 1 spray (0.5mg) in each nare, may repeat in
15 minutes;
Max 4 spray (2mg)/24hr
Yes
NSAIDs
Naproxen sodium 220mg (OTC), 275mg,
550mg tab

Tab: 220 to 440mg once

Yes
Ketorolac 15, 30mg/mL injection
solution
IM: 30-60mg once
IV: 15-30mg once
Yes
Anti-epileptics
Valproate sodium 100mg/mL injection solution
(must be diluted)
400-1000mg IV once Yes
Other*
Magnesium sulfate 500mg/mL injection solution
(must be diluted)
1-2 grams IV once Yes
*Butorphanol is FDA approved for migraine, however, it is NOT recommended due to high abuse potential and
association with chronification of migraine.

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22


Product How supplied Dosage Ranges Generic
Available?
Supportive Therapy
Antiemetics
Chlorpromazine

25mg/mL injection solution INJ: 12.5mg IV once Yes
Diphenhydramine 50mg/mL injection solution INJ: 25-50mg IV once


Metoclopramide 5, 10mg tab
5mg/mL injection solution
TAB & INJ: 5-10mg q6h PRN Yes
Ondansetron 4, 8mg tab
4, 8mg ODT
4mg/5mL oral solution
2mg/mL injection solution
PO: 4-8mg q12h PRN
INJ: 4mg IV/IM ONCE
Yes
Prochlorperazine 5, 10mg tab
5mg/mL injection solution
25mg rectal suppository
PO: 5-10mg q6h PRN
INJ: 10mg IV/IM ONCE
SUPP: 25mg q6h PRN
Yes
Promethazine 12.5, 25, 50mg tab
6.25mg/5mL oral syrup
12.5, 25mg rectal
suppository
PO: 25-50mg q6h PRN
SUPP: 25-50mg q6h PRN
Yes
Lorazepam 2mg/1mL, 4mg/1 mL
injection solution
IV: 0.5mg ONCE Yes
Haloperidol 5mg/1mL injection solution IV: 0.5mg ONCE Yes
Preventative Therapy
Beta-blockers
Propranolol 10, 20, 40, 60, 80mg tab
60, 80, 120, 160mg ER cap

20mg/5mL, 40mg/5mL oral
solution
IR tab & solution: 40-240mg 2-3 times per day in
divided doses

ER tab: 80-240mg once daily
Yes
Metoprolol 25, 37.5, 50, 75, 100mg tab IR tab: 25-100mg twice daily

Yes
Timolol 5, 10, 20mg tab 10 -15mg twice daily

Yes
Atenolol 25, 50, 100mg tab 50-100mg once daily

Yes
Tricyclic Antidepressants
Amtriptyline 10, 25, 50, 75, 100, 150mg
tab
25-150mg HS
Start low and titrate dose upward
Yes
SNRIs
Venlafaxine 25, 37.5, 50, 75, 100mg tab
37.5, 75mg, 150mg ER cap
37.5, 75, 150, 225mg ER
tab
IR tab: 75-150mg divided 2-3 times per day

ER tab & cap: 37.5-150mg daily
Yes
Anti-epileptics
Divalproex 125, 250, 500mg DR tab

250, 500mg ER tab
DR tab: 250-500mg twice daily

ER tab: 500-1000mg once daily
Yes
Topiramate 25, 50, 100, 200mg tab 25mg once daily. Titrate by 25mg weekly up to
50mg twice daily
Yes
OTC/Supplements
Magnesium Various OTC preparations 250-500mg twice daily

Yes
Riboflavin Various OTC preparations 400mg once daily

Yes


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23


Appendix E. Migraine Disability Assessment Test (MIDAS)


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24


Appendix F. Migraine Treatment Optimization Questionnaire (mTOQ-6)

The following questions refer to the times when you take treatment for your migraine
headaches. Please circle the frequency that best fits your experience in the past 4 weeks

(Please answer all the questions below.)

1. Are you able to quickly return to your normal activities (i.e. work, family, leisure, and
social activities) within 2 hours after taking your migraine medications?
Never Rarely Less than half the time Half the time or more

2. After taking you migraine medication are you pain free within 2 hours for most
attacks?
Never Rarely Less than half the time Half the time or more

3. Does one dose of your migraine medication relieve your migraine headaches and
keep them away for at least 24 hours, for most attacks?
Never Rarely Less than half the time Half the time or more

4. Is your migraine medication well tolerated?
Never Rarely Less than half the time Half the time or more

5. Are you comfortable enough with your migraine medication to be able to plan your
daily activities?
Never Rarely Less than half the time Half the time or more

6. After taking your migraine medication do you feel in control of your migraines
enough so that you feel there will be no disruption to your daily activities?
Never Rarely Less than half the time Half the time or more



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25


Recommended Solutions for Patient Reported Migraine Treatment Optimization Questionnaire
(mTOQ-6) Deficits in Treatment Optimization

Deficit areas (mTOQ-6
item)
Clinical Action
Quick return to function ξ Add migraine-specific acute treatment
ξ Change route of administration (non-oral)
ξ Raise dose
ξ Change to more effective and/or faster agent
2 hour pain free ξ Add migraine specific acute treatment
ξ Change route of administration (non-oral)
ξ Raise dose
ξ Change to more effective and/or faster agent
Sustained 24-hour pain
relief
ξ Use agenda with favorable recurrence rate and/or longer half life
ξ Consider preventive pharmacologic treatments , behavioral
treatments
Tolerability ξ Switch to more tolerable agent
ξ Change route of administration (non-oral)
Comfortable to make
plans
ξ Add migraine specific acute treatment
ξ Change route of administration (non-oral)
ξ Raise dose
ξ Change to more effective and/or faster agent
ξ Consider preventive pharmacologic treatments, behavioral
treatments
ξ Add cognitive behavioral therapy to enhance self=efficacy,
decrease anxiety, and enhance adherence
Perceived Control ξ Add migraine specific acute treatment
ξ Change route of administration (non-oral)
ξ Raise dose
ξ Change to more effective and/or faster agent
ξ Consider preventive pharmacologic treatments, behavioral
treatments
ξ Add cognitive behavioral therapy to enhance self=efficacy,
decrease anxiety, and enhance adherence



Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2017CCKM@uwhealth.org