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Migraine in a clinical context is different from “Migraine” used colloquially (bad headache). Hence, it is important to establish a clinical diagnosis of migraine prior to initiation of treatment.

Step 1: Confirm Working Diagnosis of Migraine. One of the following statements must be true.

• A) Patient reports having migraine formally diagnosed by a GP/Neurologist, and has already completed screening for secondary headaches via outpatient imaging. Patient reports has had MRI that did not show any concerning features.
  • NOTE: There is such a thing as migraine without aura, but they cannot be diagnosed in ED as they require significant secondary headache exclusion along with a journal of symptoms over 6 months.
• B) Patient presents with a clinical migraine with a preceeding aura aura, evidenced by a headache that is
  • Preceded by an aura (eg. visual halos / blurry lines in vision)
  • Severe, affecting activities of daily living.
  • Unilateral.
  • Has occurred a few times in the past. This is not a new headache pt has never had before.
  • NOTE: If statement (B) is used, please document clearly that patient is NOT being diagnosed with migraine during this ED presentation. Provide pt letter to GP with clear instructions to monitor flareups on discharge. International Headache Society guidelines require exclusion of secondary causes of headache, along with a certain number of recurrences in a year for a formal diagnosis of migraine to be made.
    

Step 2: Screen For Secondary Cause of Headache

1. Ensure all statements in the secondary headache screener are true / No suspicion of secondary headache (other than features consistent with migraine of course)
2. If any features of secondary headache are present, consult a senior CDM regarding further actions.
   

Step 3: Treat the migraine

Always ask the patient if any particular treatments have worked for them before. Most patients with confirmed migraine disorders will tell you openly about what worked for them in the past. Be very cautious of patients seeking any kind of opioids (they cause severe refractory migraines, and are generally not indicated for actual clinical migraines) – seek consultant opinion if opiates specifically requested.

Everyone gets:
1) paracetamol 1g QID regular
2) hydration: 2 satchets of hydralyte/oral replacement solution in 500ml water. **OR** 1L IV crystalloid stat bag.
3) a dark quiet room / secluded cubicle if possible (At larger EDs, this would be the Short Stay Unit). Provide ear plugs / eye mask if available.

Then add some form of migraine specific therapy (NNT)
– Chlorpromazine 25mg IV in 1L N.S. over 1-2hr (1.7)
– Prochlorperazine 12.5mg IM (2.2)
– Sumatriptan 100mg PO or 6mg SC (2.2)
– Ketorolac 30mg IM (2.4)
– Tramadol 100mg IV/IM (2.8)
– Metoclopramide 20mg IV (3.0)
– MgSO4 10mmol IV in 100ml N.S. over 1 hour (6.0)
– Aspirin 900mg (6.6)