James D. Cannon, DrPH, MS, PA-C

Disclosures

August 31, 2000

Question

In the initial assessment of an individual with headache, what are the indicators that the diagnosis may be migraine?

K. Hodges, PA-S

Response from James D. Cannon, DrPH, MS, PA-C

The key to the clinical evaluation of an acute headache is to make sure that the serious causes of the patient complaint are ruled out. These serious problems can include meningitis, intracranial hemorrhage, stroke, increased intracranial pressure, and various metabolic imbalances. If the headache is chronic in nature, and it is not a cluster or tension headache, a workup to eliminate an intracranial mass should be initiated.

Once the more serious organic causes of the headache have been ruled out, the diagnosis of a migraine may be considered and is confirmed by the history and physical exam. Keep in mind that many patients come in with the complaint of a "migraine" when in fact it is simply a tension/vascular-type headache.

The typical migraine patient is female and young to middle aged (less than 50 years). There is a strong familial pattern to these headaches. Migraines present most often without the aura (profound sensory changes), although an aura occurs in about 20% of patients.[1]

The key in the diagnosis is a thorough neurologic examination as part of the workup. Specific questions should be answered that relate to the nature and length of the headache pain as well as any aggravating factors. Additionally, it is important to assess to what degree the migraine affects the lifestyle of the patient. Depending on drug side effects and lifestyle choices, treatment of migraine may be either abortive or preventive. By far most treatment is abortive.

The physical exam should be complete and specifically focus on the neurologic system. The blood pressure should be checked for elevation (high/abnormal may indicate an infection). Visually inspect the skull/scalp for discoloration or swelling and palpate for any tenderness. Make sure to check the temporal region (to evaluate for temporal arteritis) and the temporomandibular joint for TMJ arthritis. The eyes should be checked for reactivity and equality. Loss of reactivity or fixed dilatation suggests a mass. A simple ophthalmic exam should be performed to make sure there is no papilledema that indicates increased cranial pressure. The exam should conclude with gait analysis for any focal signs.[2]

The common abortive treatments are:

  1. Imitrex (sumatriptan): subcutaneous injection, rapid relief, nonnarcotic, available in self-injector and by mouth.

  2. Midrin (isometheptene, acetaminophen, dichloralphenazone): by mouth, 2 tabs at onset followed by 1 every hour to a max of 5 per 24 hours

  3. Aspirin or nonsteroidal anti-inflammatory agents (NSAIDs)

For persons with chronic migraine headaches, all of the above should be tried in a step manner, typically beginning with the NSAIDs, then Midrin or Imitrex. However, for the acute treatment, Imitrex or even Toradol is most often used.

The preventive treatment can include the following[3]:

  1. Beta-blockers: propranolol 60-160 mg/d or metoprolol 100-200 mg/d

  2. Tricyclic antidepressant: desipramine 5-30 mg/d or amitriptyline 10-150 mg/d

  3. SSRI: Prozac 10-80 mg/d, Zoloft 50-200 mg/d, or Paxil 20-60 mg/d

  4. Calcium channel blockers: verapamil 120-480 mg/d or diltiazem 90-360 mg/d

    (* The above are listed as examples of commonly used medications in each class.)

The ultimate outcome of any migraine treatment is to find the trigger and possibly prevent the re-occurrence. If this cannot be achieved, then the treatment that minimizes rebound symptoms is ideal.

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