Skip to content
⚠️
DRAFT - Pending Review
This plan requires physician review before clinical use.

Migraine

DIAGNOSIS: Migraine ICD-10: G43.909 (Migraine, unspecified, not intractable, without status migrainosus) SCOPE: Acute migraine treatment, preventive therapy initiation, and chronic migraine management. Excludes hemiplegic migraine, migraine with brainstem aura (separate protocols).

STATUS: Draft - Pending Review


PRIORITY KEY: STAT = Immediate | URGENT = Within hours | ROUTINE = Standard | EXT = Extended/atypical cases | - = Not applicable to this setting


SECTION A: ACTION ITEMS


1. LABORATORY WORKUP

1A. Essential/Core Labs

Test Rationale Target Finding ED HOSP OPD ICU
CBC Rule out anemia, infection as headache trigger Normal STAT ROUTINE ROUTINE -
BMP Electrolyte abnormalities can trigger or mimic migraine Normal STAT ROUTINE ROUTINE -
TSH Thyroid dysfunction associated with headache disorders Normal (0.4-4.0 mIU/L) - ROUTINE ROUTINE -

1B. Extended Workup (Second-line)

Test Rationale Target Finding ED HOSP OPD ICU
ESR, CRP Rule out giant cell arteritis if age >50 with new headache Normal URGENT ROUTINE ROUTINE -
Vitamin D level Deficiency associated with increased migraine frequency >30 ng/mL - ROUTINE ROUTINE -
Magnesium (RBC) Deficiency linked to migraine; RBC level more accurate >4.2 mg/dL - ROUTINE ROUTINE -
Ferritin Iron deficiency associated with headache >50 ng/mL - ROUTINE ROUTINE -

1C. Rare/Specialized (Refractory or Atypical)

Test Rationale Target Finding ED HOSP OPD ICU
ANA, anti-dsDNA Rule out CNS lupus in atypical presentations Negative - EXT EXT -
Antiphospholipid antibodies Stroke mimic or migraine with aura risk Negative - EXT EXT -
Genetic testing (CACNA1A, ATP1A2, SCN1A) Hemiplegic migraine suspected Variant identified - - EXT -

2. DIAGNOSTIC IMAGING & STUDIES

2A. Essential/First-line

Study Timing Target Finding Contraindications ED HOSP OPD ICU
MRI Brain without contrast First migraine presentation or change in pattern Normal; rule out secondary causes MRI-incompatible devices URGENT ROUTINE ROUTINE -
CT Head non-contrast Acute severe headache ("worst headache of life") to rule out SAH No hemorrhage Pregnancy (relative) STAT STAT - -

2B. Extended

Study Timing Target Finding Contraindications ED HOSP OPD ICU
MRI Brain with contrast Atypical features, focal deficits, papilledema No enhancement Gadolinium allergy, severe renal impairment URGENT ROUTINE ROUTINE -
MRA Head/Neck Suspected vascular etiology (thunderclap, positional) Patent vessels; no dissection MRI contraindications URGENT ROUTINE ROUTINE -
CTA Head/Neck Urgent vascular imaging if MRI unavailable No aneurysm, dissection Contrast allergy, CKD STAT URGENT - -

2C. Rare/Specialized

Study Timing Target Finding Contraindications ED HOSP OPD ICU
MRV Brain Suspected cerebral venous thrombosis Patent venous sinuses MRI contraindications URGENT ROUTINE EXT -
PET scan Refractory migraine, research protocols Assess migraine generator activity Pregnancy, cost - - EXT -

3. TREATMENT

3A. Acute/Emergent

Treatment Route Indication Dosing Contraindications Monitoring ED HOSP OPD ICU
Ketorolac IV/IM First-line acute migraine in ED 30 mg IV; 15 mg IV :: IV :: :: 30 mg IV x1 (15 mg if >65y, renal impairment, or <50 kg); max 5 days NSAIDs Renal impairment; GI bleed; aspirin allergy; third trimester Renal function if repeated dosing STAT STAT - -
Metoclopramide IV Antiemetic with anti-migraine properties 10 mg IV; 20 mg IV :: IV :: :: 10-20 mg IV over 15 min; pretreat with diphenhydramine 25 mg to prevent akathisia Parkinson's disease; tardive dyskinesia; bowel obstruction Akathisia, dystonia STAT STAT - -
Prochlorperazine IV Dopamine antagonist for acute migraine 10 mg IV :: IV :: :: 10 mg IV over 2 min; pretreat with diphenhydramine 25 mg QT prolongation; Parkinson's; neuroleptic hypersensitivity Akathisia, dystonia, QTc STAT STAT - -
Diphenhydramine IV Prevent akathisia from dopamine antagonists 25 mg IV; 50 mg IV :: IV :: :: 25-50 mg IV with dopamine antagonist Glaucoma; urinary retention Sedation STAT STAT - -
Magnesium sulfate IV Migraine with aura; refractory migraine 2 g IV :: IV :: :: 2 g IV over 20 min; may repeat x1 Heart block; hypermagnesemia; myasthenia gravis BP, HR during infusion URGENT URGENT - -
Sumatriptan SC/PO Triptan-naive or triptan-responsive patient 6 mg SC; 50 mg PO; 100 mg PO :: SC/PO :: :: 6 mg SC (may repeat after 1 hr, max 12 mg/24hr) OR 50-100 mg PO (max 200 mg/24hr) Uncontrolled HTN; CAD; CVA history; MAOIs; hemiplegic migraine Chest tightness (triptan sensation vs cardiac) URGENT URGENT ROUTINE -
Valproate sodium IV Status migrainosus; refractory to first-line 500 mg IV; 1000 mg IV :: IV :: :: 500-1000 mg IV over 5 min Hepatic disease; pregnancy; urea cycle disorders; pancreatitis history LFTs, ammonia if altered mental status URGENT URGENT - -
Dihydroergotamine (DHE) IV Refractory migraine; status migrainosus 0.5 mg IV; 1 mg IV :: IV :: :: 0.5-1 mg IV q8h for up to 3 days; pretreat with antiemetic Pregnancy; CAD; uncontrolled HTN; use within 24h of triptan; severe hepatic/renal impairment BP, nausea; continuous cardiac monitoring - URGENT - -
Dexamethasone IV Prevent migraine recurrence after ED treatment 10 mg IV :: IV :: :: 10 mg IV x1 at time of ED discharge Active infection; uncontrolled diabetes Glucose if diabetic URGENT URGENT - -

3B. Symptomatic Treatments

Treatment Route Indication Dosing Contraindications Monitoring ED HOSP OPD ICU
Ondansetron IV/PO Nausea/vomiting associated with migraine 4 mg IV; 8 mg PO; 4 mg ODT :: IV/PO :: :: 4 mg IV or 8 mg PO/ODT; may repeat q8h QT prolongation; severe hepatic impairment QTc if multiple doses STAT STAT ROUTINE -
Ibuprofen PO Mild-moderate migraine 400 mg PO; 600 mg PO; 800 mg PO :: PO :: :: 400-800 mg PO at onset; max 2400 mg/day Renal impairment; GI bleed; aspirin allergy GI symptoms URGENT ROUTINE ROUTINE -
Naproxen PO Mild-moderate migraine; menstrual migraine 500 mg PO; 550 mg PO :: PO :: :: 500-550 mg PO at onset; may repeat 250 mg in 12 hr Renal impairment; GI bleed; aspirin allergy GI symptoms URGENT ROUTINE ROUTINE -
Acetaminophen/Aspirin/Caffeine PO Mild-moderate migraine (OTC option) 2 tablets PO :: PO :: :: 2 tablets (250/250/65 mg each) at onset; max 2 doses/24hr Aspirin allergy; hepatic impairment; avoid if using other acetaminophen Limit total acetaminophen <3g/day URGENT ROUTINE ROUTINE -
Rizatriptan PO Acute migraine; faster onset than sumatriptan 5 mg PO; 10 mg PO :: PO :: :: 5-10 mg PO (5 mg if on propranolol); may repeat after 2 hr; max 30 mg/24hr Same as sumatriptan; use 5 mg if on propranolol Triptan sensation - ROUTINE ROUTINE -
Eletriptan PO Acute migraine; good for return of headache 40 mg PO; 80 mg PO :: PO :: :: 40 mg PO; may repeat 40 mg after 2 hr if partial response; max 80 mg/24hr Same as sumatriptan; potent CYP3A4 inhibitors Triptan sensation - ROUTINE ROUTINE -
Naratriptan PO Slower onset but longer duration; menstrual migraine 2.5 mg PO :: PO :: :: 2.5 mg PO; may repeat after 4 hr; max 5 mg/24hr Same as sumatriptan; moderate-severe renal/hepatic impairment Triptan sensation - ROUTINE ROUTINE -
Ubrogepant PO CGRP receptor antagonist; triptan contraindications 50 mg PO; 100 mg PO :: PO :: :: 50-100 mg PO; may repeat after 2 hr; max 200 mg/24hr Strong CYP3A4 inhibitors; severe hepatic impairment None routine - ROUTINE ROUTINE -
Rimegepant PO/ODT CGRP antagonist; acute and preventive use 75 mg ODT :: PO :: :: 75 mg ODT at onset; max 75 mg/24hr for acute Strong CYP3A4 inhibitors; severe hepatic impairment None routine - ROUTINE ROUTINE -

3C. Second-line/Refractory

Treatment Route Indication Dosing Contraindications Monitoring ED HOSP OPD ICU
Nerve block (occipital) SC Refractory migraine; occipital-predominant pain 2-3 mL of 2% lidocaine + 40 mg triamcinolone :: SC :: :: Inject at greater occipital nerve bilaterally; may add lesser occipital, supraorbital Local anesthetic allergy; infection at site Immediate pain relief; monitor for vasovagal - EXT ROUTINE -
Sphenopalatine ganglion block Intranasal Refractory migraine; cluster-like features Lidocaine 4% via SphenoCath :: Intranasal :: :: Apply via intranasal device; repeat up to 3x/week Nasal pathology; local anesthetic allergy Local numbness, epistaxis - EXT EXT -
Ketamine IV Status migrainosus refractory to DHE 0.1-0.3 mg/kg/hr IV :: IV :: :: 0.1-0.3 mg/kg/hr infusion for 24-48 hr; subanesthetic dosing Uncontrolled HTN; psychosis; increased ICP Dissociation, BP, HR; requires cardiac monitoring - EXT - -

3D. Disease-Modifying or Chronic Therapies (Preventive Medications)

Treatment Route Indication Dosing Pre-Treatment Requirements Contraindications Monitoring ED HOSP OPD ICU
Propranolol PO First-line prevention; comorbid HTN or anxiety 40 mg BID; 80 mg BID; 80 mg daily LA; 160 mg daily LA :: PO :: :: Start 40 mg BID or 80 mg LA daily; titrate q2wk; target 80-240 mg/day None Asthma; COPD; bradycardia <50; heart block; decompensated HF HR, BP; watch for fatigue, depression - ROUTINE ROUTINE -
Topiramate PO First-line prevention; comorbid obesity 25 mg qHS; 50 mg BID; 75 mg BID; 100 mg BID :: PO :: :: Start 25 mg qHS; increase by 25 mg/wk; target 50-100 mg BID None Glaucoma; kidney stones; pregnancy Cognitive effects, paresthesias, weight, bicarbonate, kidney stones - ROUTINE ROUTINE -
Amitriptyline PO Prevention; comorbid insomnia, depression, TTH 10 mg qHS; 25 mg qHS; 50 mg qHS; 75 mg qHS :: PO :: :: Start 10 mg qHS; titrate by 10-25 mg q1-2wk; target 25-75 mg qHS ECG if >50 or cardiac history Cardiac conduction abnormality; recent MI; glaucoma; urinary retention Sedation, weight gain, dry mouth; ECG if >100 mg - ROUTINE ROUTINE -
Venlafaxine XR PO Prevention; comorbid depression, anxiety 37.5 mg daily; 75 mg daily; 150 mg daily :: PO :: :: Start 37.5 mg daily; increase by 37.5-75 mg q1wk; target 75-150 mg daily None Uncontrolled HTN; MAOIs; abrupt discontinuation BP at higher doses; serotonin syndrome signs - ROUTINE ROUTINE -
Valproate/Divalproex PO Prevention; comorbid bipolar or epilepsy 250 mg BID; 500 mg BID; 500 mg ER daily; 1000 mg ER daily :: PO :: :: Start 250 mg BID or 500 mg ER daily; titrate to 500-1000 mg/day LFTs, CBC Hepatic disease; pregnancy (teratogen); urea cycle disorders; pancreatitis LFTs q6mo; weight, hair loss, tremor - ROUTINE ROUTINE -
Erenumab (Aimovig) SC CGRP mAb; failed 2+ oral preventives or intolerance 70 mg SC monthly; 140 mg SC monthly :: SC :: :: 70 mg SC monthly; may increase to 140 mg monthly after 3 months None Hypersensitivity to erenumab Constipation (can be severe), injection site reactions, HTN - - ROUTINE -
Fremanezumab (Ajovy) SC CGRP mAb; alternative dosing options 225 mg SC monthly; 675 mg SC quarterly :: SC :: :: 225 mg SC monthly OR 675 mg SC quarterly None Hypersensitivity Injection site reactions - - ROUTINE -
Galcanezumab (Emgality) SC CGRP mAb; also FDA-approved for cluster 240 mg SC load; 120 mg SC monthly :: SC :: :: 240 mg SC loading dose (2 x 120 mg), then 120 mg SC monthly None Hypersensitivity Injection site reactions - - ROUTINE -
Eptinezumab (Vyepti) IV CGRP mAb; IV option for rapid onset 100 mg IV quarterly; 300 mg IV quarterly :: IV :: :: 100 mg IV q3mo; may increase to 300 mg IV q3mo None Hypersensitivity Infusion reactions (rare), nasopharyngitis - - ROUTINE -
Onabotulinumtoxin A (Botox) IM Chronic migraine (≥15 days/month); failed oral preventives 155-195 units IM :: IM :: :: 155-195 units across 31-39 injection sites q12wk; PREEMPT protocol None Infection at injection sites; myasthenia gravis Neck weakness, ptosis (rare); effect takes 2-3 cycles - - ROUTINE -
Candesartan PO Prevention; comorbid HTN; beta-blocker intolerant 8 mg daily; 16 mg daily :: PO :: :: Start 8 mg daily; may increase to 16 mg daily None Pregnancy; bilateral renal artery stenosis; hyperkalemia BP, K+, creatinine - ROUTINE ROUTINE -
Lisinopril PO Prevention; comorbid HTN 10 mg daily; 20 mg daily :: PO :: :: Start 10 mg daily; may increase to 20 mg daily None Pregnancy; angioedema history; bilateral RAS BP, K+, creatinine, cough - ROUTINE ROUTINE -
Magnesium oxide PO Supplement for prevention; migraine with aura 400 mg daily; 400 mg BID :: PO :: :: 400-800 mg daily in divided doses None Renal impairment (dose adjust) Diarrhea; check Mg level if symptomatic - ROUTINE ROUTINE -
Riboflavin (B2) PO Supplement for prevention; well-tolerated 400 mg daily :: PO :: :: 400 mg daily None None Fluorescent yellow urine (reassure patient) - ROUTINE ROUTINE -
Coenzyme Q10 PO Supplement; may benefit mitochondrial function 100 mg TID; 300 mg daily :: PO :: :: 100-300 mg daily None None None - ROUTINE ROUTINE -

4. OTHER RECOMMENDATIONS

4A. Referrals & Consults

Recommendation ED HOSP OPD ICU
Neurology/Headache specialist referral for chronic or refractory migraine management and preventive optimization - ROUTINE ROUTINE -
Pain management referral for interventional procedures (nerve blocks, Botox) in chronic refractory cases - - ROUTINE -
Behavioral medicine/Psychology for cognitive behavioral therapy addressing pain catastrophizing and comorbid anxiety/depression - - ROUTINE -
Physical therapy for cervicogenic component and postural contribution to headaches - - ROUTINE -
Sleep medicine evaluation if sleep disorder contributing to migraine frequency - - ROUTINE -
Ophthalmology evaluation to rule out visual triggers and ensure appropriate vision correction - - ROUTINE -
OB/GYN consultation for menstrual migraine management and hormonal contraception optimization - - ROUTINE -

4B. Patient Instructions

Recommendation ED HOSP OPD
Return immediately for sudden severe headache different from typical migraine ("worst headache of life") which may indicate hemorrhage STAT - ROUTINE
Return immediately for headache with fever, stiff neck, or altered mental status which may indicate infection STAT - ROUTINE
Maintain headache diary tracking frequency, triggers, and medication use to guide treatment optimization - ROUTINE ROUTINE
Limit acute medication use to ≤10 days/month to prevent medication overuse headache URGENT ROUTINE ROUTINE
Take acute medications at first sign of migraine for best efficacy rather than waiting for severe pain - ROUTINE ROUTINE
Identify and avoid personal triggers (stress, sleep changes, skipped meals, alcohol, specific foods) - ROUTINE ROUTINE

4C. Lifestyle & Prevention

Recommendation ED HOSP OPD
Regular sleep schedule (7-8 hours, consistent bedtime/wake time) as irregular sleep is a major trigger - ROUTINE ROUTINE
Regular meals to avoid fasting-triggered migraine; do not skip breakfast - ROUTINE ROUTINE
Aerobic exercise (30 min moderate activity 5x/week) shown to reduce migraine frequency - ROUTINE ROUTINE
Stress management through relaxation techniques, mindfulness, or biofeedback - ROUTINE ROUTINE
Caffeine moderation (≤200 mg/day equivalent to 2 cups coffee) and consistent daily intake - ROUTINE ROUTINE
Adequate hydration (at least 64 oz water daily) as dehydration can trigger migraine - ROUTINE ROUTINE
Limit alcohol especially red wine which is a common trigger - ROUTINE ROUTINE

SECTION B: REFERENCE


5. DIFFERENTIAL DIAGNOSIS

Alternative Diagnosis Key Distinguishing Features Tests to Differentiate
Tension-type headache Bilateral, pressing/tightening quality, mild-moderate intensity, no nausea/vomiting, no photo/phonophobia (may have one) Clinical criteria; no specific test
Cluster headache Unilateral, periorbital, severe, autonomic features (lacrimation, rhinorrhea, ptosis), 15-180 min, occurs in clusters Clinical history; may see MRI normal
Medication overuse headache Daily or near-daily headache; using acute medications ≥10-15 days/month Headache diary; improves with medication withdrawal
Secondary headache (intracranial pathology) New onset, progressive, positional, neurological deficits, thunderclap MRI/MRA brain; consider LP
Giant cell arteritis Age >50, scalp tenderness, jaw claudication, visual changes, elevated ESR/CRP ESR, CRP, temporal artery biopsy
Idiopathic intracranial hypertension Positional headache, papilledema, pulsatile tinnitus, visual obscurations, obesity LP with opening pressure; MRI/MRV
Cervicogenic headache Unilateral, occipital-frontal radiation, neck movement triggers, reduced ROM Physical exam; C-spine imaging; diagnostic block
Trigeminal neuralgia Brief electric shock-like pain, unilateral V2/V3, triggered by touch/eating MRI for vascular loop; clinical criteria

6. MONITORING PARAMETERS

Parameter Frequency Target/Threshold Action if Abnormal ED HOSP OPD ICU
Headache diary (frequency, severity, duration) Continuous at home <4 headache days/month; 50% reduction with preventive Adjust preventive therapy; consider Botox or CGRP mAb - ROUTINE ROUTINE -
Acute medication use days Monthly ≤10 days/month Counsel on MOH; may need withdrawal protocol - ROUTINE ROUTINE -
HIT-6 or MIDAS score Every 3 months 50% improvement in disability score Escalate preventive therapy - - ROUTINE -
BP (if on beta-blocker or ARB) Each visit <130/80; HR >50 Adjust dose; switch agent if bradycardia - ROUTINE ROUTINE -
LFTs (if on valproate) Baseline, 3 months, then q6mo Normal Discontinue if >3x ULN - ROUTINE ROUTINE -
Bicarbonate (if on topiramate) Baseline, 3 months >18 mEq/L Consider dose reduction or discontinuation - ROUTINE ROUTINE -
Weight Each visit Stable (topiramate: may decrease; others: may increase) Adjust medications based on weight changes - ROUTINE ROUTINE -
Cognitive function (if on topiramate) Each visit No word-finding difficulty or cognitive slowing Reduce dose or switch agent - ROUTINE ROUTINE -

7. DISPOSITION CRITERIA

Disposition Criteria
Discharge home Pain controlled; able to tolerate PO; no red flags; follow-up arranged
Admit to floor Status migrainosus requiring IV therapy >24hr; inability to tolerate PO; need for DHE protocol
Admit to ICU Rare; only if hemodynamic instability from medications or concern for secondary cause requiring monitoring
Outpatient follow-up Within 2-4 weeks for new diagnosis; 4-12 weeks for established patients on preventives

8. EVIDENCE & REFERENCES

Recommendation Evidence Level Source
Triptans effective for acute migraine Class I, Level A Marmura et al. Headache 2015
CGRP monoclonal antibodies for prevention Class I, Level A Goadsby et al. NEJM 2017 (erenumab STRIVE)
OnabotulinumtoxinA for chronic migraine Class I, Level A Dodick et al. Headache 2010 (PREEMPT pooled)
Topiramate for migraine prevention Class I, Level A Silberstein et al. Arch Neurol 2004
Metoclopramide effective for acute migraine Class II, Level B Friedman et al. Ann Emerg Med 2008
Dexamethasone reduces recurrence Class I, Level B Singh et al. Acad Emerg Med 2008
Propranolol for migraine prevention Class I, Level A Linde et al. Cochrane 2004
Gepants (ubrogepant, rimegepant) for acute migraine Class I, Level A Dodick et al. JAMA 2019 (ubrogepant)
Magnesium for migraine with aura prevention Class II, Level B Peikert et al. Cephalalgia 1996
Exercise as effective as topiramate for prevention Class II, Level B Varkey et al. Cephalalgia 2011

CHANGE LOG

v1.0 (January 27, 2026) - Initial template creation - Comprehensive acute and preventive treatment coverage - Includes gepants and CGRP monoclonal antibodies - Structured dosing format for order sentence generation