Internal Medicine

0521779407-14 CUNY1086/Karliner 0 521 77940 7 June 4, 2007 21:16

Migraine Headache 983

tests

■Diagnosis made clinically

■Lab tests & brain imaging are normal

■Lumbar puncture opening pressure & CSF studies normal

differential diagnosis

■Brain mass lesion or subdural hematoma excluded by history & brain

imaging

■Pseudotumor cerebri excluded clinically (& by LP if necessary)

■Postconcussion syndrome & hypothyroidism excluded clinically

■Brain imaging indicated for prominent change in headache quality

or frequency

management

■Depends on severity & prior treatment

General measures

■Headache diary may elucidate precipitants

■Ensure adequate relaxation & exercise

■Reduce caffeine & alcohol use

■Physical therapy, relaxation techniques, hot or cold packs may help

■Hormone replacement may reduce attacks during menopause

specific therapy

Indications

■Abortive meds indicated for rare headaches (<1 per week); prophy-

lactic meds used for more frequent moderate to severe headaches

Treatment options

■Abortive agents for head pain

➣Acetaminophen

➣Aspirin

➣Ibuprofen

➣Codeine/acetaminophen or codeine/aspirin

➣Caffeine/butabutal/ASA or acetaminophen

➣Ergotamine/caffeine

➣Dihydroergotamine nasal spray or IM, SC or IV w/ metaclo-

pramide

➣5-HT agonists: sumatriptan, rizatriptan, zolmitriptan, naratrip-

tan, frovatriptan, eletriptan, almotriptan

Narcotic analgesics in rare instances: meperidine intramus-

cularly or butorphanol tartrate by nasal spray