Migraine Headache

Diagnosis/Definition

Headache present at least 2 months, with a stereotypical pattern and intermittent quality. A stereotypical pattern for the headache is unilateral throbbing pain which may radiate.

Initial Diagnosis and Management

• History and physical examination.
• Neurologic examination by primary physician.
• MR/CT imaging indicated if:
• There are focal neurological signs/symptoms.
• The headache pattern is changing.
• The history suggests seizure disorder.
• Identify and reduce triggers.
• Educational behavioral therapies (e.g., Neurology Clinic’s headache class, biofeedback, stress management). Referrals can be directed to the Neurology headache class or Biofeedback.
• Lifestyle evaluation (cessation of smoking, discussion of contraceptive methods, regular exercise).

• Weekly or more frequently: emphasis must be on prophylaxis. Abortive agents can be regularly used no more than 2x per week to avoid risk for rebound.
• Weekly or less frequently: generally only abortive therapy required unless severe impact on patient’s life, unresponsive to abortive agents, etc..

Ongoing Management and Objectives

• Prophylactic therapy: Reduces frequency and/or intensity by at least 50%. Appropriate agents include tricyclics, beta-blockers, valproic acid, calcium channel blockers, or topiramate.
• Abortive therapy: Reduce severity of attacks. Appropriate abortive agents include isometheptene, non-steroidal anti-inflammatory agents, ergotamine, triptans.
• Criteria for head imaging as stated above.

Indications for Specialty Care Referral

If diagnosis in doubt.

If focal neurological symptoms or signs.

If patient has failed at least two trials of appropriate therapies.

Criteria for Return to Primary Care

Headache pattern stabilizing on no medication or on chronic medication.

In opinion of neurologist, headaches can be managed by primary care with neurology input on a prn basis.