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FACP. Colegio de médicos de Tarragona Nº 4305520 / fgcapriles@gmail.com




Thursday, May 12, 2016

Headache management

emDocs - May 11, 2016 - Author: Adibi S - Edited by: Koyfman A and Long B
"This discussion will focus on managing headache symptoms in the ED. Red flags in the H&P, diagnostic testing, differential diagnoses, etc. are outside the scope of this review, as is a comprehensive review of the different types of headaches (both primary and secondary). If interested in further info, go here: http://www.emdocs.net/acute-headache-emergency-department/
Pearls and Pitfalls
  • Opioids should NOT be routinely used for acute migraine headaches. There are multiple side effects that have been noted including addictive potential. Additionally, opioids have a high association with medication overuse headaches/rebound headaches and therefore can increase the risk of relapse and subsequent bounce back to ER. Can also promote chronic migraines.
  • Magnesium. Studies have shown that routine serum studies do not reflect true total magnesium stores. Migraine sufferers may have magnesium deficiency (hypothesized to be due to genetic defect resulting inability to properly absorb magnesium, increased renal wasting with excretion of excessive amounts, and/or low nutritional intake, etc). While double-blind placebo controlled trials have mixed results, researchers believe this may be due to involvement of both magnesium deficient and non-deficient patients. Since both oral and intravenous formulations are widely available and relatively safe this can provide a significant benefit to those patients with chronic migraines who may be magnesium deficient (reportedly up to half of migraine patients).
  • There is controversy surrounding use of steroids (typically dexamethasone at 10-25mg IM or IV).
    • Up to date does recommend use to reduce risk of early relapsing headache.
    • Up to 49% of patients will have a recurrence of headache within 72 hours. While recurrence is dependent on choice of abortive agent, sex, age, and severity of migraine at presentation there is evidence (meta-analysis of 7 randomized trials) that dexamethasone may decrease the frequency of such recurrences in up to 10% of patients (number needed to treat was 9). Additionally, dexamethasone does not provide an immediate benefit for relief of symptoms. Thus it is important to weight the benefits versus the risk of administering this medication. While one dose of dexamethasone has been shown to have no increased adverse effects compared to placebo, it is important to note that repeated exposure is associated with significant side effects including avascular necrosis of bone.
  • Abortive treatments for migraine are usually more effective if they are given early in the course of the headache; a large single dose tends to work better than repetitive small doses."