Migraine

Headache History
*** Interim History
*** Headache Description
• Character: ***
• Aura: ***
• Associated Symptoms: ***
• Frequency: ***
• Triggers: ***
• Other Migraine Features: No symptoms suggestive of POTS. No palpitations or chest pain. No changes in bowel habits. Current Medications
• Abortive: ***
• Preventive: *** Previously Tried Medications
• Abortive: ***
• Preventive: *** Plan
• Migraine Abortives: ***
• Migraine Preventives: ***
• Discussed the potential side effects of current medications. Patient was understanding and agreeable. Migraine Counseling:
• Instructed patient to take abortive medication at headache onset.
• Advised to rest in a quiet, dark environment during headache episodes.
• Reviewed common migraine triggers: artificial sweeteners, MSG, aged cheese, skipped meals, altered sleep patterns, intense exertion.
• Recommended lifestyle modifications: regular exercise, consistent meal and sleep schedule, avoidance of smoking and excessive caffeine.
• Advised against frequent use of OTC analgesics due to risk of medication-overuse headache.

Migraine Treatment Summary

Preventive Medications:

• Oral Preventives: Topiramate, Magnesium oxide, Valproate, Propranolol, Candesartan, Amitriptyline, Nortriptyline, Verapamil, Venlafaxin, Lamotrigine

• CGRP-targeted therapies (typically require prior authorization or trial of traditional agents):

  Erenumab, Fremanezumab, Galcanezumab, Eptinezumab, Rimegepant, Atogepant

• Menstrual Migraine: Continuous combined oral contraceptives (without aura) or progestin-only (with aura)

• For Chronic Migraine: OnabotulinumtoxinA (Botox) per PREEMPT protocol

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Abortive Medications:

At Home:

• Triptans: Sumatriptan (oral, nasal, subcutaneous), Rizatriptan, Zolmitriptan (oral/nasal), Eletriptan, Naratriptan, Almotriptan, Frovatriptan

• NSAIDs: Naproxen, Ibuprofen, Ketorolac

• CGRP Receptor Antagonists (Gepants): Rimegepant, Ubrogepant, Zavegepant (nasal spray)

• Others: Prochlorperazine, Hydroxyzine, Metoclopramide

In Hospital / ED:

• IV Magnesium (1gm one time in ED or 1gm q8h for 1-2 days if admitted)

• Ketorolac (30mg IV q8h pre)

• Metoclopramide (10mg IV Q8h pre)

• Prochlorperazine (10mg IV Q8h pre)

• Chlorpromazine (25mg IV Q8h pre)

• Dexamethasone (10mg once)

• Valproic Acid (500-1000mg once)

• DHE (Dihydroergotamine) Protocol

  • Metoclopramide or prochlorperazine 10 mg IV → wait 15 minutes
  • DHE 0.25 mg IV slow push over 2 minutes
  • If well tolerated, escalate gradually q8h to reach 1mg (next dose is 0.5mg, then 0.75 then 1mg). You may repeat 1mg q8h until headache subsides.
  • See DHE protocol note below:

DHE Protocol Note Template

DHE Protocol for Status Migrainosus

Day 1 –

First Dose:

1. Premedication:

   • Metoclopramide 10 mg IV over 2-5 minutes

   • Wait 10-15 minutes before DHE

2. DHE Administration:

   • Dihydroergotamine (DHE) 0.25 mg IV slow push over 2-3 minutes

   • Monitor vitals (BP, HR) during and after administration

   • Observe for nausea, chest pain, or leg cramps

3. Hydration:

   • Normal saline 250-500 mL IV bolus if needed for support

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If well tolerated:

Second Dose: DHE 0.5mg

Third Dose: DHE 0.75mg

—

If well tolerated:

Day 2 and onward (up to 3-5 days inpatient)

• DHE 1 mg IV every 8 hours (max 3 mg/day)

• Continue antiemetic 10 minutes before each dose

Optional Adjuncts:

• Dexamethasone 10 mg IV daily × 3 days

• IV fluids to support BP and hydration

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**Contraindications:**

• Pregnancy

• Cardiovascular or peripheral vascular disease

• Uncontrolled hypertension

• Recent use of triptans or other ergots (within 24 hrs)

• Severe hepatic/renal impairment

Migraine resources

>> Diagnostic criteria for migraine

>> Migraine prints for patient counselling 

>> Headache diary Ready for Print

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Example for a headache note 
Headache history: 
Mr. B is a 45-year-old right handed man who is presenting to the clinic today for follow up for migraine. Patient started to have significant headache at age of 25. Initially it was mild/moderate in severity and occurred around once a month then increased in frequency over the years to almost 3-4 episodes of severe headache per week. He used to take OTC analgesics prn to control his headache initially till he was diagnosed with migraine at age of 30 and started on migraine medications as noted below. Interim history: 
Last clinic visit, patient was started on topiramate for prevention that was gradually increased to 50mg bid and naproxen 500mg bid prn. Patient reports decrease in headache frequency over that past few months to once a Headache description:
-Character: pressure like headache, starts in the back of the head then spreads to involve both frontal regions.
-Aura: visual in the form of bright spots and zigzag lines 10 minutes before the headache
-Asscociated symptoms: nausea but no vomiting, sensory phobias
-Frequency: currently once a month
-Increased by: skipping a meal, artificial sweeteners, physical stress
-Decreased by: staying in dark quiet place.
-Other manifestations of migraine: no symptoms suggestive of POTS,  no palpitation or chest pain, no change in bowel habits. Current medications: 
Abortive: Naproxen 500 mg bid prn
Preventive: Topiramate 50 mg bid Previously tried medications: 
Abortive:  hydroxyzine stopped due to significant sedation.
Preventive: magnesium oxide didn’t work at 500 mg bid Plan:
– Migraine abortives: continue on Naproxen 500 mg bid prn
– Migraine preventives: will increase topamax to 50 qam and 75 qpm
– Discussed the potential side effects of the current medications, patient was understanding and agreeable. – Migraine counselling:
– patient was instructed to take the abortive medications once the headache starts.
– He was advised to stay in a calm quite place during headache.
– Discussed the need to avoid common migraine triggers (artificial sweeteners, food preservative (MSG), aged cheese, skipping meals, change in wake/sleep cycle and intense physical exertion)
– Lifestyle changes that help migraine: physical exercise, fixed meal time, fixed sleep/wake cycle, avoid smoking and highly caffeinated products.
– Patient was advised to avoid OTC analgesics which can increase migraine frequency and can cause medication overuse headache.