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.
