Migraine - acute - 1 

Migraine in the ED

The disabling headache caused by migraine is usually able to be managed by patients and their GP.
Patients who present to the ED will usually have tried oral medication, so parenterally administered medication is usually indicated in the ED. 

Pitfalls of diagnosing migraine 

Migraine as a clinical diagnosis in the ED is a diagnosis of exclusion.
Other causes of severe headache such as subarachnoid haemorrhage and meningitis must be ruled out before diagnosis is made.  

Classification  

Migraine is typically classified as
1) Migraine with aura (previously 'classic migraine')
2) Migraine without aura (previously 'common migraine') ~ 80% of all migraines     

International Headache Society classification

Diagnostic criteria for migraine without aura 

1. At least five attacks fitting these criteria
2. Headache lasts 4-72 hrs
3. Nausea/ vomiting/ photophobia/ phonophobia
4. No evidence of other disease
5. Headache with at least two of:
  - unilateral
  - throbbing
  - moderate to sever intensity
  - aggravated by physical activity   

Diagnostic criteria for migraine with aura 

1. At least two attacks fitting these criteria
2. No evidence of other disease
3. At least three of:
  - one or more aura that resolved completely
  - aura onset over more than four minutes
  - aura duration less than 60 minutes
  - headache onset within one hour of aura finishing.     

Uncommon, but recognised patterns of migraine also include:

- Basilar migraine : a migraine with an aura involving the brainstem (symptoms include ataxia, dysarthria, vertigo, tinnitus and/or changes in consciousness and cognition).

- Opthalmoplegic migraine : associated with acute attacks of third nerve palsy with accompanying dilation of the pupil. In this setting, the differential diagnosis includes an intracranial aneurysm or chronic sinusitis complicated by a mucocele. The ophthalmoplegia can last from hours to months.

- Hemiplegic migraine : distinguished by the accompanying hemiplegia, which can be part of the aura, or the headache may precede the onset of hemiplegia. Hemiplegic migraine can be familial and may last for days or weeks, clinically simulating a stroke.

- Abdominal migraine : involve symptoms of abdominal pain and vomiting without headache, usually in children.