| Type | Features | Duration |
|---|---|---|
| Migraine without aura | Unilateral, pulsating, moderate-severe, nausea/vomiting, photophobia/phonophobia, worse with activity | 4โ72 hours |
| Migraine with aura | Visual (scintillating scotoma), sensory, or speech aura preceding headache by 5โ60 min | 4โ72 hours |
| Tension-type | Bilateral, pressing/tightening ("band-like"), mild-moderate, NO nausea/vomiting | 30 minโ7 days |
| Cluster | Unilateral orbital/temporal, severe, with autonomic features (lacrimation, rhinorrhea, ptosis, miosis). Male predominance. | 15โ180 min, occurs in clusters |
| Diagnosis | Key Features | Workup | Treatment |
|---|---|---|---|
| SAH | Thunderclap onset, "worst headache of life", neck stiffness | CT head (98% if <6h) then LP for xanthochromia | Secure aneurysm (coil/clip), nimodipine, ICU |
| Meningitis | Fever + headache + neck stiffness + photophobia. Kernig/Brudzinski signs | LP (CSF analysis), blood cultures | Empiric: ceftriaxone + vancomycin + dexamethasone de Gans & van de Beek, NEJM 2002 |
| Giant Cell Arteritis | Age >50, temporal tenderness, jaw claudication, vision changes, elevated ESR/CRP | ESR, CRP, temporal artery biopsy | Prednisone 60 mg/day immediately. Do NOT wait for biopsy |
| Idiopathic Intracranial HTN | Young obese female, daily headache, papilledema, pulsatile tinnitus, transient visual obscurations | MRI (empty sella, flattened globes), LP (opening pressure >25 cm H2O) | Weight loss, acetazolamide 500 mg BID, serial visual fields IIHTT, JAMA 2014 |
| Cerebral Venous Thrombosis | Headache (often progressive) + seizures or focal deficits. Risk: OCP, pregnancy, thrombophilia | MRI + MRV (filling defect in sinus). D-dimer may be elevated | Anticoagulation with heparin, even if hemorrhagic infarct present |
| Intracranial Mass | Progressive, worse in morning, with nausea/vomiting, focal deficits, seizures, papilledema | MRI brain with contrast | Dexamethasone (reduce edema), neurosurgery + oncology |
| Severity | Treatment |
|---|---|
| Mild-moderate | NSAIDs (Ibuprofen (Advil) 400โ800mg, Naproxen (Aleve) 500mg) + Metoclopramide (Reglan) 10mg or antiemetic |
| Moderate-severe | Sumatriptan (Imitrex) 6mg SC or 50โ100mg PO. Contraindicated in CAD, uncontrolled HTN, prior stroke. |
| ER/refractory | "Migraine cocktail": Ketorolac (Toradol) 30mg IV + Prochlorperazine (Compazine) 10mg IV + Diphenhydramine (Benadryl) 25mg IV + IV fluids |
| Status migrainosus | Dexamethasone (Decadron) 10mg IV + above cocktail. Dihydroergotamine (DHE) protocol if refractory. |
| Setting | Treatment | Details |
|---|---|---|
| Acute (abortive) | High-flow O2 12-15 L via NRB | First-line. 78% response in 15 min. Cohen et al, JAMA 2009 |
| Acute (abortive) | Sumatriptan 6 mg SC | Second-line. SC only (oral too slow for 15-180 min attacks) |
| Prophylaxis (first-line) | Verapamil 240-960 mg/day | ECG monitoring (heart block risk at high doses). Takes 1-2 weeks to work |
| Bridge therapy | Prednisone 60 mg/day x 5d then taper | Rapid relief while verapamil takes effect |
| Refractory | Lithium, galcanezumab, occipital nerve block | Goadsby et al, NEJM 2019 |
| Drug | Dose | Use | Key Notes |
|---|---|---|---|
| Sumatriptan (Imitrex) | 50โ100mg PO, 6mg SC | Acute migraine | Triptan class -5-HT1B/1D agonist. Avoid in CAD, prior stroke. |
| Ketorolac (Toradol) | 15โ30mg IV/IM | Acute migraine (ER) | NSAID. Max 5 days. Renal caution. |
| Prochlorperazine (Compazine) | 10mg IV | Anti-emetic + anti-migraine | Dopamine antagonist. Give with diphenhydramine to prevent EPS. |
| Topiramate (Topamax) | 25โ100mg BID | Prophylaxis | Weight loss, paresthesias, kidney stones, word-finding difficulty. |
| Erenumab (Aimovig) | 70โ140mg SC monthly | Prophylaxis | CGRP antibody. Few side effects. Constipation. |
Patient: 48F presents with "worst headache of my life" that reached peak intensity within 30 seconds while exercising. Associated with nausea and neck stiffness. No prior headache history. Exam: GCS 15, mild photophobia, no focal deficits.
Workup: Non-contrast CT head (within 2 hours of onset): negative for hemorrhage. Given early presentation, CT has ~98-100% sensitivity. Decision made to proceed with LP given high clinical suspicion.
LP results: Tube 1: 850 RBCs. Tube 4: 780 RBCs (no clearing). Xanthochromia positive by spectrophotometry.
Assessment: SAH with negative CT but positive LP (xanthochromia + non-clearing RBCs). Approximately 2-5% of SAH cases are CT-negative.
Management: CTA head: 4 mm anterior communicating artery aneurysm. Neurosurgery consulted. Endovascular coiling performed. Nimodipine 60 mg PO q4h for vasospasm prevention x 21 days. ICU monitoring with daily TCDs. Good outcome.
Patient: 32F with known migraines (6/month) presents with severe throbbing left-sided headache x 4 days that has not responded to home sumatriptan (used 3 doses) or ibuprofen. Nausea, vomiting, photophobia. Unable to work or sleep.
Exam: VS stable. Neurologic exam normal. No papilledema. No meningismus.
Assessment: Status migrainosus (migraine lasting >72 hours). Also using triptans >10 days/month, raising concern for medication overuse headache.
Management: Migraine cocktail: ketorolac 30 mg IV + prochlorperazine 10 mg IV + diphenhydramine 25 mg IV + 1L NS. Added dexamethasone 10 mg IV (reduces 72h recurrence by 25%). Pain improved 2h later. Discharged with: referral to headache specialist, topiramate 25 mg daily (prophylaxis), instructions to limit triptan use to <=2 days/week.
Patient: 72F with new-onset right temporal headache x 2 weeks, worse with chewing (jaw claudication). Also reports 10 lb weight loss and shoulder stiffness. No headache history.
Exam: Tender, non-pulsatile right temporal artery. Visual acuity 20/20 bilaterally (no vision loss yet). Fundoscopic exam normal.
Labs: ESR 95 (normal <30), CRP 8.2 (normal <0.5). CBC: mild normocytic anemia. Platelets 450k (reactive thrombocytosis).
Assessment: Giant cell arteritis (GCA). New headache age >50 + jaw claudication + markedly elevated ESR/CRP. High risk for irreversible vision loss if untreated.
Management: Started prednisone 60 mg/day immediately (do NOT wait for biopsy). Temporal artery biopsy scheduled within 1 week (remains positive up to 2 weeks after steroids). Ophthalmology consulted for baseline exam. Biopsy returned: granulomatous arteritis with giant cells. Slow steroid taper over 12-18 months guided by symptoms and ESR/CRP. Added PPI + calcium/vitamin D + DEXA scan for steroid bone protection.