Headache & Migraine
Primary (migraine, tension, cluster) vs secondary (SAH, meningitis, mass, temporal arteritis). Red flags: thunderclap onset, worst ever, focal neuro, fever, papilledema, age > 50 new onset. Triptans for acute migraine.
🔍 Overview
Primary Headache Classification
| Type | Features | Duration |
|---|---|---|
| Migraine without aura | Unilateral, pulsating, moderate-severe, nausea/vomiting, photophobia/phonophobia, worse with activity | 4–72 hours |
| Migraine with aura | Visual (scintillating scotoma), sensory, or speech aura preceding headache by 5–60 min | 4–72 hours |
| Tension-type | Bilateral, pressing/tightening ("band-like"), mild-moderate, NO nausea/vomiting | 30 min–7 days |
| Cluster | Unilateral orbital/temporal, severe, with autonomic features (lacrimation, rhinorrhea, ptosis, miosis). Male predominance. | 15–180 min, occurs in clusters |
Red flags (SNOOP): S ystemic (fever, weight loss, cancer, HIV) · N eurologic (focal deficits, papilledema) · O nset sudden (thunderclap → SAH until proven otherwise) · O lder (new onset > 50 → GCA) · P ositional/progressive/precipitated by Valsalva.
Secondary Headache Causes (Do Not Miss)
| 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 |
🚨 Management
Acute Migraine Treatment
| Severity | Treatment |
|---|---|
| Mild-moderate | NSAIDs (Ibuprofen (Advil) 400–800mg, Naproxen (Aleve) 500mg) + Metoclopramide (Reglan) 10mg or antiemetic |
| Moderate-severe | Sumatriptan (Imitrex) 6mg SC or 50–100mg 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. |
Migraine Prophylaxis (≥ 4 headache days/month)
- Topiramate (Topamax) 25–100mg BID -weight loss side effect
- Propranolol (Inderal) 40–160mg daily -also treats anxiety, tremor
- Amitriptyline (Elavil) 10–75mg QHS -good for comorbid insomnia/tension-type
- Valproate (Depakote) 500–1500mg daily -teratogenic, weight gain
- CGRP monoclonal antibodies: Erenumab (Aimovig), Fremanezumab (Ajovy), Galcanezumab (Emgality)
Cluster Headache Treatment
| 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 |
Dexamethasone for migraine recurrence prevention: Singh & Alter, Acad Emerg Med 2008 A single dose of dexamethasone 10 mg IV in the ED reduces 72-hour migraine recurrence by ~25% (NNT = 9). Should be given with the migraine cocktail, especially for status migrainosus or patients with history of frequent ED visits.
🧪 Workup
When to Image
- Thunderclap headache → CT head STAT → if negative, LP for xanthochromia (SAH)
- New neurologic deficits → CT/MRI + consider CTA/MRA
- New headache age > 50 → ESR, CRP (GCA) + imaging
- Positional headache → MRI brain + possible LP (CSF pressure)
- Progressive or worsening pattern → MRI with contrast
- Typical migraine with normal exam → generally NO imaging needed
💊 Medications
| Drug | Dose | Use | Key Notes |
|---|---|---|---|
| Sumatriptan (Imitrex) | 50–100mg PO, 6mg SC | Acute migraine | Triptan class -5-HT1B/1D agonist. Avoid in CAD, prior stroke. |
| Ketorolac (Toradol) | 15–30mg 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) | 25–100mg BID | Prophylaxis | Weight loss, paresthesias, kidney stones, word-finding difficulty. |
| Erenumab (Aimovig) | 70–140mg SC monthly | Prophylaxis | CGRP antibody. Few side effects. Constipation. |
📋 On Rounds
Pimp Questions
What is the workup for thunderclap headache?
Thunderclap = maximal intensity within seconds to 1 minute. #1 concern: subarachnoid hemorrhage (SAH). Workup: (1) Non-contrast CT head - sensitivity ~98-100% within 6h, drops to ~50% by day 5. (2) If CT negative, LP - look for xanthochromia (yellow CSF from bilirubin, appears 6-12h after bleed) and elevated RBCs that do NOT clear with successive tubes. (3) If SAH confirmed, CTA or catheter angiography to find the aneurysm. Perry et al, BMJ 2011 Also consider other causes of thunderclap: RCVS, cervical artery dissection, CVT, pituitary apoplexy.
Why are triptans contraindicated in cardiovascular disease?
Triptans are 5-HT1B/1D agonists. The 5-HT1B receptor is found on cranial blood vessels (causing vasoconstriction -the therapeutic effect) but ALSO on coronary arteries. In patients with CAD, triptans can cause coronary vasospasm → myocardial ischemia → MI. Contraindicated in: known CAD, prior MI/stroke/TIA, Prinzmetal angina, uncontrolled HTN, hemiplegic migraine.
What is medication overuse headache and how do you manage it?
MOH = chronic daily headache caused by regular use of acute headache medications. Triptans > 10 days/month, NSAIDs/acetaminophen > 15 days/month. The medication itself perpetuates the headache cycle. Management: (1) Educate the patient, (2) Withdraw the offending medication (can do abruptly for triptans, taper for opioids), (3) Start preventive therapy, (4) Bridge with a short course of steroids or DHE during withdrawal period.
What is the acute treatment for cluster headache?
High-flow oxygen 12-15 L/min via NRB mask x 15 min is first-line (70% response rate within 15 min). Second-line: sumatriptan 6 mg SC (not oral - too slow for cluster). Prophylaxis: verapamil 240-960 mg/day is first-line preventive. Bridge with short course of prednisone while titrating verapamil. Cohen et al, JAMA 2009
What is the sensitivity of CT for SAH over time?
CT sensitivity for SAH declines rapidly with time: within 6 hours: ~98-100%, 12 hours: ~93%, 24 hours: ~90%, 3 days: ~80%, 1 week: ~50%. This is why a negative CT within 6 hours on a modern scanner may be sufficient to rule out SAH without LP in low-risk patients. Perry et al, BMJ 2011 However, the Ottawa SAH Rule and clinical judgment should guide the decision. If CT is done >6h after onset, LP remains necessary.
What are the CGRP monoclonal antibodies and how do they work?
CGRP (calcitonin gene-related peptide) is a key mediator of migraine pathophysiology, released by trigeminal neurons causing vasodilation and neurogenic inflammation. CGRP monoclonal antibodies block this pathway. Erenumab (Aimovig) targets the CGRP receptor; fremanezumab (Ajovy) and galcanezumab (Emgality) target the CGRP ligand. Given monthly SC injection. Reduce migraine days by 50% in ~50% of patients. Few side effects (constipation, injection site reactions). Goadsby et al, NEJM 2017
How do you evaluate for giant cell arteritis (GCA) in a patient >50 with new headache?
GCA is a medical emergency because of risk of irreversible vision loss. Workup: (1) ESR (typically >50, often >100) and CRP (elevated). (2) Temporal artery biopsy is the gold standard (skip lesions can cause false negatives, so biopsy >2 cm). (3) Start prednisone 60 mg/day immediately - do NOT wait for biopsy results. Biopsy remains positive for 1-2 weeks after steroid initiation. (4) If vision symptoms present, admit for IV methylprednisolone 1g x 3 days. Proven et al, Neurology 2009
What is the "migraine cocktail" and why does it work?
The ED migraine cocktail targets multiple pathways: (1) Ketorolac 30 mg IV - NSAID, anti-inflammatory + analgesic. (2) Prochlorperazine 10 mg IV (or metoclopramide) - dopamine antagonist, anti-emetic + direct anti-migraine effect via dopamine pathway blockade. (3) Diphenhydramine 25 mg IV - prevents akathisia/EPS from prochlorperazine + mild sedation. Some protocols add IV fluids (dehydration is a trigger) and magnesium 2g IV (reduces cortical spreading depression). Friedman et al, Ann Emerg Med 2008
When should you start migraine prophylaxis?
Start prophylaxis when: (1) >=4 headache days per month. (2) Attacks are severe and disabling despite acute treatment. (3) Acute medication use >=2 days/week (risk of MOH). (4) Patient preference. (5) Contraindication to acute therapies. First-line options: topiramate (best evidence), propranolol, amitriptyline. CGRP antibodies for patients who fail 2+ oral preventives. Give any preventive an adequate trial of 2-3 months before declaring failure. Silberstein et al, Neurology 2012
Clinical Examples
📋 Case 1 - Thunderclap Headache: SAH Workup
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.
📋 Case 2 - Status Migrainosus in the ED
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.
📋 Case 3 - New Headache in Elderly: Giant Cell Arteritis
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.
⚡ Summary
Sort Primary From Secondary First
Primary: migraine, tension-type, cluster. Secondary is what kills: subarachnoid hemorrhage, meningitis, mass lesion, giant cell arteritis, venous sinus thrombosis, idiopathic intracranial hypertension, carbon monoxide. The history does most of this work, and imaging is directed by red flags rather than by severity.
SNOOP Red Flags
Systemic (fever, weight loss, cancer, HIV, immunosuppression) · Neurologic (focal deficit, papilledema, altered consciousness) · Onset sudden · Older, new onset over 50 · Pattern change or positional, or worsening with Valsalva. Any one of these means image before treating.
Thunderclap Means Subarachnoid Until Proven Otherwise
Maximal intensity within seconds, the worst headache of life. Non-contrast CT is about 98% sensitive within 6 h of onset and falls off after that, so a negative CT beyond that window needs a lumbar puncture for xanthochromia. Also consider cervical artery dissection, venous sinus thrombosis and reversible cerebral vasoconstriction syndrome in the same presentation.
New Headache Over 50 Means Check for GCA
ESR and CRP, and ask about jaw claudication, scalp tenderness, visual symptoms and polymyalgia. Start high-dose steroids immediately on clinical suspicion; do not wait for the temporal artery biopsy, which stays positive for weeks after treatment starts. The vision loss is irreversible and can be bilateral within days.
Acute Migraine: Treat Early and With Combinations
Triptans work best given early in the attack, before central sensitization sets in, which is why waiting to see if it passes makes the treatment less effective. Contraindicated in coronary and cerebrovascular disease and in hemiplegic or basilar migraine. In the emergency department, an antidopaminergic (metoclopramide or prochlorperazine) plus IV fluids plus an NSAID outperforms opioids. Give diphenhydramine with the antidopaminergic to prevent akathisia and dystonia.
Add Dexamethasone Before Discharge
A single 10 mg IV dose reduces 72-hour migraine recurrence by roughly 25%, NNT 9. It does nothing for the headache in front of you, so give it alongside the abortive rather than instead of it. Avoid opioids and butalbital entirely: they cause medication-overuse headache and worsen the long-term pattern.
Prophylaxis at 4 or More Headache Days a Month
Choose the agent by comorbidity: propranolol or metoprolol (avoid in asthma and depression), topiramate (weight loss, but teratogenic and causes cognitive slowing), amitriptyline (helps with insomnia and coexisting tension headache), valproate (never in a person who could become pregnant), and CGRP monoclonal antibodies for refractory disease. Give any agent an 8 to 12 week trial at an adequate dose before calling it a failure.
Cluster Headache Has Its Own Treatment
Severe unilateral orbital or temporal pain lasting 15 to 180 min with ipsilateral autonomic features, in a patient who paces rather than lies still. Abort with high-flow oxygen 12 to 15 L/min by non-rebreather plus subcutaneous sumatriptan; oral triptans are too slow for an attack this short. Verapamil is the prophylactic of choice, with a steroid taper as a bridge while it takes effect, and ECG monitoring as the dose rises.
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