Evidence-Based Emergency Department Management of Migraine and Other Primary Headaches (Pharmacology CME and Pain Management CME)

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Delivery Method:	Online
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Publication Date: October 2023 (Volume 25, Number 10)

CME Credits: 4 AMA PRA Category 1 Credits™, 4 ACEP Category I credits, 4 AAFP Prescribed credits, and 4 AOA Category 2-B CME credits. CME expires 10/01/2026.

Specialty CME Credits: Included as part of the 4 credits, this CME activity is eligible for 2 Pharmacology CME credits and 1 Pain Management credit, subject to your state and institutional approval.

Authors

Peer Reviewers

Abstract

Headache is the fifth most common presenting chief complaint in emergency departments, and it is vital to quickly rule out life-threatening secondary causes. Though there are many medications, new and old, that can be used to treat primary headache, the evidence for their effectiveness can be conflicting. This review describes the pathology, workup, and treatment for migraine and other primary headaches based on the best available evidence, including novel medications, nerve blocks, and strategies for preventing postdrome recurrence. Other headache disorders, including cluster headache, medication overuse headache, and chronic migraine are also reviewed.

Case Presentations

A 36-year woman presents with a pounding left-sided headache associated with nausea that has persisted for 12 hours…

• She reports having similar headaches about twice monthly, and though they usually resolve with sumatriptan, she typically visits the ED about once a year for refractory events. This headache began gradually 12 hours prior and, despite use of oral sumatriptan 100 mg, ibuprofen 800 mg, and acetaminophen 1000 mg, it has not improved.
• Her physical examination is unremarkable, including normal vital signs, a normal fundoscopic and visual field examination, and a normal neurologic examination. A point-of-care urine pregnancy test is negative.
• You administer metoclopramide 10 mg IV and ketorolac 15 mg IV, but she reports only minimal relief. You wonder what your best next treatment option is…

A 45-year man with a history of infrequent, episodic migraine presents with an unremitting headache for 1 week…

• He reports an average of 3 severe headaches per year since high school, and they usually resolve completely with 10 mg oral rizatriptan. For the past 5 months, in association with increased stress at work, he reports an increase in headache frequency. At first, they were occurring about once per week and responding to ibuprofen, but over the last month, he has had headaches nearly every day. Initially, he was getting relief with a combination of 10 mg oral rizatriptan once daily and 800 mg ibuprofen twice daily, but now these medications are not working at all. His headaches are associated with photophobia and phonophobia, and they are preventing him from functioning at work.
• His medical history is unremarkable, and the review of systems is otherwise normal. His physical examination, including vital signs, ophthalmologic, and neurologic examinations are normal.
• You wonder what you can offer him in the ED that might help…

A 53-year woman with migraine presents with a severe headache. She reports a history of 4 headache days per week, which has been going on for more than 10 years...

• She typically manages her headaches with oral eletriptan, naproxen, acetaminophen, Excedrin^® migraine, and a combination butalbital/acetaminophen/caffeine drug. In the past she has been treated with botulinum toxin injections and oral topiramate. She is typically forced to present to an ED 3 times per year for management of severe headache, but because she has previously experienced dystonic reactions, she is reluctant to receive an antidopaminergic medication.
• As you begin your evaluation, she says, “Doc, just give me my Dilaudid.” You can see she is in severe pain, but you wonder whether giving opioids is the best option in her care…

Accreditation:

EB Medicine is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.