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Acute Treatment of Migraine at a Health Care Facility

Acute Treatment of Migraine at a Health Care Facility - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Clinical Practice Guidelines, Neurology, Related


Patient presents to a Health Care Facility
with Severe/Disabling Headache
Diagnose primary headache type
Diagnosis of Migraine or
Probable Migraine
Administer First Line Medication
ξDHE 1 mg injection (IV or IM) if available at facility OR
ξSumatriptan 4-6 mg subcutaneous injection
Administer Supportive Medications
1. IV fluid rehydration therapy
2. Anti-nausea therapy (e.g., metoclopramide 5-10 mg IV, ondansetron 4 mg IV)
3. May also consider diphenhydramine 25-50 mg IV
4. May also consider lorazepam 0.5 mg IV and/or haloperidol 0.5 mg IV
If Inadequate Response to Previous Therapy, Consider
ξKetorolac 15-30 mg IV unless contraindicated OR
ξMagnesium 1 g, IV infusion over 30-60 min OR
ξValproate sodium 500 mg IV
Secondary Headache
ξExample conditions that may cause
secondary headache include intracranial
infection, bleed, or mass, temporal
arteritis, sinusitis, and febrile illness
Primary Headache
ξTypes include cluster, tension-
type, and migraine
ξTension-type headache is by
definition of mild or moderate
intensity
ξIf secondary headache is not
suspected, and primary headache
type is unclear, consider a
diagnosis of probable migraine
Dihydroergotamine (DHE)
ξEffective regardless of the
duration of headache
ξIf DHE IV injection is not
available at a particular
UW Health facility, it may
be ordered for
administration at the UW
Health Infusion Center.
Call the Infusion Center to
schedule.
NO
Diagnosis of cluster or
tension-type headache
YES
Opioids for Headache
ξOpioids are NOT recommended and
should only be given only as a last
resort in extraordinary circumstances
ξUse of opioids to treat migraine pain
is associated with development of
medication overuse headache and
chronification of migraine
Further evaluation,
treatment, referral, and
follow up as indicated
(outside of guideline scope)
Secondary
headache
suspected?
To Reduce Repeated Visits,
Follow Up with PCP or Headache Specialist Should be Scheduled
Before the Patient Leaves
Appendix C.
Acute Treatment of
Migraine at a Clinic,
Urgent Care Center,
or Emergency Department
Medication Overuse and Chronic Migraine
ξOften occur together and are a
common cause of multiple
presentations to urgent care/ED for
acute migraine treatment
ξFollow up with primary care or a
headache specialists is recommended
Any Contraindications to DHE or Triptans?
ξTaken a triptan or DHE within previous 24 hours*
ξPoorly tolerated or inadequate response to triptans or DHE in the past
ξUncontrolled hypertension
ξHistory of any type of vascular disease
*Exception: May use sumatriptan injection in patients who have taken oral
sumatriptan in the previous 24 hours.
YES
NO
Last Reviewed: 05/2016
Contact CCKM for questions.
Migraine – Adult – Ambulatory/
Emergency Department Clinical
Practice Guideline
Copyright © 201� University of Wisconsin Hospital s and Clinics Authority
Cont ac t : Lee V erm eul en, CCK M @uwheal th. org Las t Revi s ed: 05/2016
CCKM@uwhealth.org