TABLE 2194 Emergency Department Treatment Options for Migraine Headache

Dexamethasone has been touted as effective in reducing the rate of recurrent migraine following standard treatment. 2 In one ED-based RCT, patients received either 20 mg intravenous dexamethasone or placebo after standard migraine therapy. A significant reduction in the rate of 48- to 72-h recurrent migraine was found in the dexamethasone group as compared to the placebo group.19

Special mention is reserved for the use of opioid analgesics in migraine. Meperidine is still used as an acute migraine treatment despite several studies that have shown it to be less effective than other agents.20 The frequent use of opioids in chronic and recurrent headache conditions may lead to adverse effects, and may even exacerbate headaches.20 While some patients may require opioid analgesics, the preferred treatment is one of the numerous, more effective alternatives to opioids. 2

Pregnant Women Migraines generally improve during pregnancy, especially after the first trimester. Nonpharmacologic therapy, such as rest and ice, should be tried first, but in patients with intractable headache or nausea and vomiting, medications may be used. 11 Acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs) are considered class B by the US Food and Drug Administration (i.e., no evidence of risk in pregnant women, but there are no controlled trials) and can be used. However, NSAIDs should be used very cautiously, if at all, in the third trimester, since they inhibit labor and decrease amniotic fluid volume. Metoclopramide, another class B drug, can be very useful, especially if there is significant nausea and vomiting. 11

Prophylaxis Patients with frequent recurrent migraines may benefit from prophylactic medications, such as b blockers without intrinsic sympathomimetic activity (atenolol, metoprolol, nadolol, propanolol), calcium-channel blockers, tricyclic antidepressants, or NSAIDs. However, obstetric or neurologic consultation should be obtained before starting these drugs in the ED. In patients already on prophylaxis and experiencing breakthrough migraines, drugs should be titrated up to maximally tolerated doses for several months before concluding that a given medication is ineffective. They also must be withdrawn slowly to prevent rebound headaches. 2

TENSION-TYPE HEADACHES Previously, extracranial muscle tension was thought to be a causative factor in tension-type headaches. However, this relationship has been questioned, given the problem of demonstrating muscle tension and the difficulty of determining whether it is a cause or merely an epiphenomenon. More recent theories suggest that tension-type headaches and migraines may share a common pathophysiology and that they represent different ends of a clinical spectrum.7

Tension-type headaches are defined in such a way as to distinguish them from migraines. Therefore, they are described as bilateral, nonpulsating, not worsened by exertion, and not associated with nausea or vomiting.3 However, patients with severe tension-type headaches may indeed have nausea and vomiting, and mild migraine might easily fit the description of a tension-type headache.7

Treatment for mild headaches consists of simple analgesics or NSAIDs. For severe tension-type headaches, treatment is the same as for migraines, given the difficulty of distinguishing between the two entities.

CLUSTER HEADACHES Cluster headaches are generally rare (prevalence rates of 0.4 percent of the general population), and they are very short-lived even without treatment. Unlike other primary headaches, they are more common in men, and onset is usually after 20 years of age.

Dysfunction of the trigeminal nerve is believed to cause cluster headaches, and the fact that they respond to 5-HT 1D agonists suggests a common mechanism with

migraines.21

Cluster headaches are characterized by very severe, unilateral orbital, supraorbital, or temporal pain lasting 15 to 180 min. The pain is such that patients can rarely lie still, and most are pacing and restless. The headaches are associated with at least one of the following signs on the ipsilateral side: conjunctival injection, lacrimation, nasal congestion, rhinorrhea, facial swelling, miosis, or ptosis. They tend to occur in "clusters," that is, daily on the same side of the face for several weeks, before remitting for anywhere from weeks to years.3

Given the short duration of cluster headaches, any medication used in their treatment must act very rapidly. Oxygen is effective in up to 70 percent of patients, and DHE and sumatriptan have also been shown to be rapidly effective. Oral agents are unlikely to be effective for acute attacks, given the long time for absorption and the short duration of cluster headaches, but NSAIDs may be useful in reducing the frequency and severity of future attacks. 21

DISPOSITION OF PATIENTS WITH PRIMARY HEADACHE SYNDROMES Regardless of the type of primary headache, poor response to treatment should heighten suspicion of a secondary cause and prompt emergent investigations. However, improvement of a presumed primary headache as a result of treatment does not rule out secondary causes.4 Patients who respond well to ED management may usually be discharged with appropriate follow-up. Occasionally, a patient with intractable migraine may require admission for more aggressive pain control.

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