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