Migraine¶

VERSION: 1.0 CREATED: January 29, 2026 REVISED: January 29, 2026 STATUS: Approved

DIAGNOSIS: Migraine / Status Migrainosus

ICD-10: G43.909 (Migraine, unspecified, not intractable), G43.919 (Migraine, unspecified, intractable), G43.901 (Migraine, unspecified, not intractable, with status migrainosus), G43.911 (Migraine, unspecified, intractable, with status migrainosus), G43.109 (Migraine with aura, not intractable), G43.709 (Chronic migraine without aura, not intractable)

CPT CODES: 85025 (CBC), 80053 (CMP), 84703 (hCG (women of childbearing age)), 84443 (TSH), 83735 (Magnesium), 85652 (ESR), 82306 (Vitamin D), 82728 (Ferritin), 83090 (Homocysteine), 86235 (Autoimmune panel (ANA), 70450 (CT head without contrast), 70551 (MRI brain without contrast), 70553 (MRI brain with and without contrast), 70544 (MRA head), 93000 (ECG), 62270 (LUMBAR PUNCTURE), 89051 (Cell count (tubes 1 and 4)), 84157 (Protein), 82945 (Glucose), 87483 (CSF meningitis panel), 96374 (Prochlorperazine IV), 96365 (Magnesium sulfate IV), J0585 (OnabotulinumtoxinA (Botox))

SYNONYMS: Migraine headache, migraine with aura, migraine without aura, classic migraine, common migraine, status migrainosus, intractable migraine, refractory migraine, chronic migraine, menstrual migraine, vestibular migraine, hemiplegic migraine, retinal migraine, basilar migraine, migraine with brainstem aura, acephalgic migraine, silent migraine, ocular migraine, ophthalmic migraine, hormonal migraine, catamenial migraine, episodic migraine, transformed migraine, complicated migraine, severe headache, sick headache, vascular headache

SCOPE: Evaluation and management of acute migraine, status migrainosus, and chronic migraine in adults. Covers abortive therapy, rescue treatment for refractory attacks, and preventive medication initiation. Includes special considerations for pregnancy and medication overuse. Excludes secondary headache disorders, cluster headache, and tension-type headache.

DEFINITIONS: - Migraine: Recurrent headache disorder manifesting in attacks lasting 4-72 hours with unilateral location, pulsating quality, moderate-severe intensity, aggravation by activity, and associated nausea/vomiting or photo/phonophobia - Status Migrainosus: Debilitating migraine attack lasting >72 hours - Chronic Migraine: ≥15 headache days/month for >3 months, with migraine features on ≥8 days/month - Medication Overuse Headache (MOH): Headache occurring ≥15 days/month in patient with pre-existing headache using acute medications regularly for >3 months

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

1. LABORATORY WORKUP¶

1A. Essential/Core Labs¶

Test	ED	HOSP	OPD	ICU	Rationale	Target Finding
CBC (CPT 85025)	URGENT	ROUTINE	ROUTINE	-	Rule out anemia, infection	Normal
CMP (CPT 80053)	URGENT	ROUTINE	ROUTINE	-	Electrolyte abnormalities, renal function	Normal
hCG (women of childbearing age) (CPT 84703)	STAT	STAT	ROUTINE	-	Pregnancy status affects treatment options	Document status
TSH (CPT 84443)	-	ROUTINE	ROUTINE	-	Thyroid dysfunction can cause headache	Normal
Magnesium (CPT 83735)	URGENT	ROUTINE	ROUTINE	-	Low levels may contribute to migraines	>1.8 mg/dL

1B. Extended Workup (Second-line)¶

Test	ED	HOSP	OPD	ICU	Rationale	Target Finding
ESR (CPT 85652) / CRP (CPT 86140)	URGENT	ROUTINE	ROUTINE	-	If GCA or inflammatory cause suspected (>50 years, new onset)	Normal
Vitamin D (CPT 82306)	-	ROUTINE	ROUTINE	-	Deficiency associated with migraine frequency	>30 ng/mL
Ferritin (CPT 82728)	-	ROUTINE	ROUTINE	-	Iron deficiency associated with migraine	>50 ng/mL
Homocysteine (CPT 83090)	-	-	EXT	-	Elevated levels associated with migraine with aura	Normal

1C. Rare/Specialized¶

Test	ED	HOSP	OPD	ICU	Rationale	Target Finding
Lumbar puncture	URGENT	URGENT	-	-	Thunderclap headache, suspected SAH, IIH, meningitis	See LP section
Autoimmune panel (ANA (CPT 86235), etc.)	-	EXT	EXT	-	If vasculitis or autoimmune cause suspected	Negative

2. DIAGNOSTIC IMAGING & STUDIES¶

2A. Essential/First-line¶

Study	ED	HOSP	OPD	ICU	Timing	Target Finding	Contraindications
CT head without contrast (CPT 70450)	STAT	URGENT	-	-	If thunderclap, worst headache, focal deficits, altered mental status	Rule out hemorrhage, mass	None in emergency
MRI brain without contrast (CPT 70551)	-	ROUTINE	ROUTINE	-	New headache pattern, focal features, refractory to treatment	Normal; rule out structural cause	Pacemaker, metal implants

2B. Extended¶

Study	ED	HOSP	OPD	ICU	Timing	Target Finding	Contraindications
MRI brain with and without contrast (CPT 70553)	-	ROUTINE	ROUTINE	-	If mass, infection, or inflammation suspected	Rule out enhancement	Contrast allergy, renal disease
MRV or CT venogram	URGENT	URGENT	-	-	Suspected cerebral venous thrombosis	Patent venous sinuses	Per modality
MRA head (CPT 70544)	-	ROUTINE	ROUTINE	-	Suspected vasculopathy, aneurysm	Normal vasculature	Per modality
ECG (CPT 93000)	STAT	STAT	-	-	Prior to DHE or triptan use	Normal QTc, no ischemia	None

LUMBAR PUNCTURE (CPT 62270)¶

Indication: Thunderclap headache, suspected SAH (CT negative), suspected IIH (papilledema), suspected meningitis, atypical features

Timing: URGENT after CT excludes mass effect

Study	ED	HOSP	OPD	ICU	Rationale	Target Finding
Opening pressure	STAT	STAT	-	-	IIH diagnosis	10-20 cm H2O (elevated >25 suggests IIH)
Cell count (tubes 1 and 4) (CPT 89051)	STAT	STAT	-	-	Infection, SAH	WBC <5; RBC 0 or clearing
Protein (CPT 84157)	STAT	STAT	-	-	Infection, inflammation	15-45 mg/dL
Glucose (CPT 82945)	STAT	STAT	-	-	Infection	>60% serum
Xanthochromia	STAT	STAT	-	-	SAH if CT negative	Negative
Gram stain and culture (CPT 87205, 87070)	STAT	STAT	-	-	Bacterial meningitis	No organisms
CSF meningitis panel (CPT 87483)	URGENT	URGENT	-	-	Viral/bacterial pathogens	Negative

3. TREATMENT¶

3A. Acute/Abortive Treatment - Mild-Moderate Attacks¶

Treatment	Route	Indication	Dosing	Contraindications	Monitoring	ED	HOSP	OPD	ICU
Acetaminophen	PO	-	1000 mg :: PO :: once :: 1000 mg PO once, max 3000 mg/day	Hepatic disease, chronic alcohol use	LFTs if frequent use	-	ROUTINE	ROUTINE	-
Ibuprofen	PO	-	400-800 mg :: PO :: once :: 400-800 mg PO once	Renal disease, GI bleeding, aspirin allergy	Renal function	-	ROUTINE	ROUTINE	-
Naproxen sodium	PO	-	500-825 mg :: PO :: once :: 500-825 mg PO once	Same as ibuprofen	Renal function	-	ROUTINE	ROUTINE	-
Aspirin	PO	-	900-1000 mg :: PO :: once :: 900-1000 mg PO once	Bleeding disorder, aspirin allergy	Bleeding	-	ROUTINE	ROUTINE	-
Excedrin (ASA/APAP/caffeine)	PO	-	2 tab :: PO :: once :: 2 tablets PO once	Per components	Risk of MOH	-	-	ROUTINE	-

3B. Acute/Abortive Treatment - Moderate-Severe Attacks (Triptans)¶

Treatment	Route	Indication	Dosing	Contraindications	Monitoring	ED	HOSP	OPD	ICU
Sumatriptan SC	SC	-	6 mg :: SC :: once :: 6 mg SC once; may repeat in 2h; max 12 mg/24h	CAD, stroke/TIA, uncontrolled HTN, hemiplegic/basilar migraine, pregnancy	Chest tightness, BP	STAT	STAT	-	-
Sumatriptan PO	PO	-	50-100 mg :: PO :: once :: 50-100 mg PO once; may repeat in 2h; max 200 mg/24h	Same as SC	Same	-	ROUTINE	ROUTINE	-
Sumatriptan nasal	IN	-	20 mg :: IN :: - :: 20 mg intranasal; may repeat in 2h; max 40 mg/24h	Same as SC	Same	URGENT	ROUTINE	ROUTINE	-
Rizatriptan	PO	-	5-10 mg :: PO :: - :: 5-10 mg PO (ODT available); may repeat in 2h; max 30 mg/24h	Same; 5 mg if on propranolol	Same	-	ROUTINE	ROUTINE	-
Eletriptan	PO	-	40 mg :: PO :: - :: 40 mg PO; may repeat in 2h; max 80 mg/24h	Same; severe hepatic impairment	Same	-	ROUTINE	ROUTINE	-
Zolmitriptan	PO	-	2.5-5 mg :: PO :: - :: 2.5-5 mg PO or nasal; may repeat in 2h; max 10 mg/24h	Same	Same	-	ROUTINE	ROUTINE	-

3C. Acute/Abortive Treatment - CGRP Antagonists (Gepants)¶

Treatment	Route	Indication	Dosing	Contraindications	Monitoring	ED	HOSP	OPD	ICU
Ubrogepant	PO	-	50-100 mg :: PO :: - :: 50-100 mg PO; may repeat in 2h; max 200 mg/24h	CYP3A4 inhibitors; no cardiovascular contraindications	LFTs periodically	-	ROUTINE	ROUTINE	-
Rimegepant	PO	-	75 mg :: PO :: once daily :: 75 mg PO once daily; ODT formulation	CYP3A4 inhibitors	LFTs periodically	-	ROUTINE	ROUTINE	-
Zavegepant nasal	IN	-	10 mg :: IN :: once daily :: 10 mg intranasal once daily	None significant	Local irritation	-	ROUTINE	ROUTINE	-

3D. ED/Inpatient Treatment - Status Migrainosus ("Headache Cocktail")¶

Treatment	Route	Indication	Dosing	Pre-Treatment Requirements	Contraindications	Monitoring	ED	HOSP	OPD	ICU
IV fluids	IV	-	75-125 mL/hr :: - :: once :: NS or LR 1L bolus, then 75-125 mL/hr	-	Heart failure, volume overload	I/O	STAT	STAT	-	-
Prochlorperazine IV (CPT 96374)	IV	-	10 mg :: IV :: - :: 10 mg IV slow push over 5-10 min; may repeat in 30 min	-	QT prolongation, Parkinson's	QTc, akathisia, dystonia	STAT	STAT	-	-
Metoclopramide IV	IV	-	10-20 mg :: IV :: - :: 10-20 mg IV over 15-30 min; may repeat in 30 min	-	QT prolongation, Parkinson's, seizures	QTc, akathisia, dystonia	STAT	STAT	-	-
Diphenhydramine IV	IV	-	25-50 mg :: IV :: - :: 25-50 mg IV to prevent akathisia (give with antiemetic)	-	Glaucoma, urinary retention	Sedation	STAT	STAT	-	-
Ketorolac IV	IV	-	30 mg :: IV :: - :: 30 mg IV (15 mg if >65y or CrCl <50); max 2 doses	-	Renal disease, GI bleeding, anticoagulation	Renal function	STAT	STAT	-	-
Dexamethasone IV	IV	-	10 mg :: IV :: once :: 10 mg IV once (reduces recurrence)	-	Active infection, uncontrolled DM	Glucose	URGENT	URGENT	-	-
Magnesium sulfate IV (CPT 96365)	IV	-	2 g :: IV :: - :: 2 g IV over 20-30 min	-	Renal failure, myasthenia	Mg levels, reflexes	URGENT	URGENT	-	-
Valproate sodium IV	IV	-	500-1000 mg :: IV :: - :: 500-1000 mg IV over 15-30 min	-	Pregnancy, hepatic disease, mitochondrial disease	Ammonia, LFTs	URGENT	URGENT	-	-

3E. ED/Inpatient - Refractory/Second-Line Therapy (DHE Protocol)¶

Prerequisites: Check ECG, BP <140/90, negative pregnancy test. Avoid if triptan within 24h or CAD/CVA history.

Treatment	Route	Indication	Dosing	Contraindications	Monitoring	ED	HOSP	OPD	ICU
Dihydroergotamine (DHE)	IV	-	10 mg :: IV :: q8h :: Premedicate: metoclopramide 10 mg IV + diphenhydramine 25 mg IV; Test dose: 0.5 mg IV over 1 min; If tolerated: 0.5-1 mg IV q8h	Pregnancy, CAD, CVA, uncontrolled HTN, triptan <24h, ergot allergy	BP, chest pain, nausea	URGENT	STAT	-	-
DHE nasal	IN	-	0.5 mg :: - :: once :: 0.5 mg per nostril (1 mg total); may repeat once in 15 min; max 3 mg/24h	Same as IV	Same	-	ROUTINE	ROUTINE	-

3F. Pregnancy-Safe Options¶

Treatment	Route	Indication	Dosing	Contraindications	Monitoring	ED	HOSP	OPD	ICU
Acetaminophen	IV	-	1000 mg :: IV :: q8h :: 1000 mg PO/IV q8h; max 3000 mg/day	Hepatic disease	LFTs	STAT	STAT	ROUTINE	-
Metoclopramide	IV	-	10 mg :: IV :: q8h :: 10 mg IV/PO q8h	Parkinson's	Akathisia	STAT	STAT	ROUTINE	-
Ondansetron	IV	-	4-8 mg :: IV :: q8h :: 4-8 mg IV/PO q8h	QT prolongation (caution 1st trimester)	QTc	URGENT	ROUTINE	ROUTINE	-
Magnesium sulfate	IV	-	2 g :: IV :: once :: 2 g IV once	Renal failure	Reflexes, respiratory	URGENT	URGENT	-	-
Nerve block (occipital)	-	-	2-3 mL :: - :: - :: Lidocaine 1% or bupivacaine 0.25%, 2-3 mL per side	Local anesthetic allergy	Local reaction	-	ROUTINE	ROUTINE	-
Sumatriptan (if refractory)	SC	-	6 mg :: SC :: - :: 6 mg SC x1 (pregnancy registry data reassuring)	Per triptan list; discuss risks	Standard	-	EXT	EXT	-

3G. Preventive Medications - First-Line¶

Treatment	Route	Indication	Dosing	Contraindications	Monitoring	ED	HOSP	OPD	ICU
Propranolol	PO	-	40-80 mg/day :: PO :: - :: Start 40-80 mg/day in divided doses; target 80-240 mg/day	Asthma, heart block, bradycardia, depression	HR, BP	-	ROUTINE	ROUTINE	-
Metoprolol	PO	-	25-50 mg :: PO :: BID :: Start 25-50 mg BID; target 100-200 mg/day	Same as propranolol	HR, BP	-	ROUTINE	ROUTINE	-
Topiramate	PO	-	25 mg :: PO :: QHS :: Start 25 mg QHS; increase by 25 mg/week to 50-100 mg BID	Kidney stones, pregnancy (teratogenic), glaucoma	Bicarbonate, cognitive effects	-	ROUTINE	ROUTINE	-
Amitriptyline	-	-	10-25 mg :: PO :: QHS :: Start 10-25 mg QHS; target 50-150 mg QHS	Glaucoma, urinary retention, cardiac arrhythmia	QTc, anticholinergic effects	-	ROUTINE	ROUTINE	-
Venlafaxine XR	PO	-	37.5 mg :: PO :: daily :: Start 37.5 mg daily; target 75-150 mg daily	Uncontrolled HTN, MAOI use	BP, serotonin syndrome	-	ROUTINE	ROUTINE	-

3H. Preventive Medications - CGRP Monoclonal Antibodies¶

Treatment	Route	Indication	Dosing	Contraindications	Monitoring	ED	HOSP	OPD	ICU
Erenumab (Aimovig)	SC	-	70-140 mg :: SC :: monthly :: 70-140 mg SC monthly	Hypersensitivity; caution with constipation, HTN	BP, constipation	-	-	ROUTINE	-
Fremanezumab (Ajovy)	SC	-	225 mg :: SC :: monthly :: 225 mg SC monthly OR 675 mg SC quarterly	Hypersensitivity	Injection site reactions	-	-	ROUTINE	-
Galcanezumab (Emgality)	SC	-	240 mg :: SC :: monthly :: 240 mg SC loading, then 120 mg SC monthly	Hypersensitivity	Injection site reactions	-	-	ROUTINE	-
Eptinezumab (Vyepti)	IV	-	100-300 mg :: IV :: - :: 100-300 mg IV q3 months	Hypersensitivity	Infusion reactions	-	ROUTINE	ROUTINE	-

3I. Preventive Medications - Other¶

Treatment	Route	Indication	Dosing	Contraindications	Monitoring	ED	HOSP	OPD	ICU
Valproate	PO	-	250-500 mg :: PO :: BID :: Start 250-500 mg BID; target 500-1500 mg/day	Pregnancy, hepatic disease	LFTs, ammonia	-	ROUTINE	ROUTINE	-
OnabotulinumtoxinA (Botox) (CPT J0585)	IM	-	155-195 units :: IM :: - :: 155-195 units IM q12 weeks (chronic migraine only)	Infection at injection sites, myasthenia	Spread of toxin effect	-	-	ROUTINE	-
Atogepant (Qulipta)	PO	-	10-60 mg :: PO :: daily :: 10-60 mg PO daily	Severe hepatic impairment	LFTs	-	-	ROUTINE	-
Rimegepant (preventive)	-	-	75 mg :: - :: - :: 75 mg every other day	CYP3A4 inhibitors	LFTs	-	-	ROUTINE	-
Magnesium oxide	PO	-	400-600 mg :: PO :: daily :: 400-600 mg PO daily	Renal failure	Diarrhea	-	ROUTINE	ROUTINE	-
Riboflavin (Vitamin B2)	PO	-	400 mg :: PO :: daily :: 400 mg PO daily	None significant	None	-	-	ROUTINE	-
CoQ10	PO	-	100 mg :: PO :: TID :: 100 mg TID	None significant	None	-	-	ROUTINE	-

4. OTHER RECOMMENDATIONS¶

4A. Referrals & Consults¶

Recommendation	ED	HOSP	OPD	ICU	Indication
Neurology consult	URGENT	ROUTINE	-	-	Status migrainosus, refractory to ED treatment
Headache specialist referral	-	ROUTINE	ROUTINE	-	Chronic migraine, medication overuse, refractory disease
Ophthalmology consult	URGENT	URGENT	ROUTINE	-	Papilledema, visual symptoms suggesting IIH
Pain management referral	-	-	ROUTINE	-	Refractory chronic migraine, nerve block consideration
Behavioral health referral	-	ROUTINE	ROUTINE	-	Comorbid anxiety/depression, biofeedback interest
Physical therapy	-	-	ROUTINE	-	Cervicogenic component, trigger point therapy

4B. Patient/Family Instructions¶

Recommendation	ED	HOSP	OPD
Keep headache diary (frequency, severity, triggers, medications)	ROUTINE	ROUTINE	ROUTINE
Treat migraine early - medications more effective within first hour	ROUTINE	ROUTINE	ROUTINE
Avoid medication overuse: limit triptans to ≤9 days/month, NSAIDs to ≤14 days/month	ROUTINE	ROUTINE	ROUTINE
Identify and avoid personal triggers	ROUTINE	ROUTINE	ROUTINE
Follow up with neurologist in 2-4 weeks if new diagnosis	ROUTINE	ROUTINE	ROUTINE
Follow up with PCP or neurologist for preventive medication monitoring	-	ROUTINE	ROUTINE
Return to ED if: worst headache of life, fever, neurologic deficits, altered mental status	ROUTINE	ROUTINE	ROUTINE

4C. Lifestyle & Prevention¶

Recommendation	ED	HOSP	OPD
Maintain regular sleep schedule (7-8 hours)	-	ROUTINE	ROUTINE
Regular exercise (30 min, 5 days/week)	-	ROUTINE	ROUTINE
Stress management (biofeedback, relaxation techniques, CBT)	-	ROUTINE	ROUTINE
Stay well-hydrated (64+ oz water daily)	ROUTINE	ROUTINE	ROUTINE
Avoid known triggers: alcohol, aged cheese, MSG, processed meats, irregular meals	-	ROUTINE	ROUTINE
Limit caffeine to consistent moderate intake (<200 mg/day)	-	ROUTINE	ROUTINE
Consider migraine glasses (FL-41 tint) for photophobia	-	-	ROUTINE

5. DIFFERENTIAL DIAGNOSIS¶

Alternative Diagnosis	Key Distinguishing Features	Tests to Differentiate
Tension-type headache	Bilateral, pressing/tightening, mild-moderate, no nausea/vomiting	Clinical history; no photophobia
Cluster headache	Unilateral periorbital, autonomic features (tearing, rhinorrhea), short duration (15-180 min), circadian pattern	Clinical pattern; response to O2/triptans
Medication overuse headache	Chronic daily headache, >15 days/month, frequent analgesic use	Medication diary; improves with withdrawal
Subarachnoid hemorrhage	Thunderclap onset, "worst headache of life," neck stiffness	CT head, LP if CT negative
Idiopathic intracranial hypertension	Papilledema, visual obscurations, pulsatile tinnitus, bilateral pressure	LP with elevated OP (>25 cm H2O)
Giant cell arteritis	Age >50, new headache, jaw claudication, scalp tenderness, visual symptoms	ESR/CRP elevated, temporal artery biopsy
Cerebral venous thrombosis	Progressive headache, seizures, focal deficits, pregnancy/OCP	MRV/CTV
Cervicogenic headache	Neck pain, limited ROM, triggered by neck movement	Cervical exam, imaging
Trigeminal autonomic cephalalgia	Short attacks, autonomic features, response to indomethacin (some types)	Clinical pattern
Brain tumor	Progressive headache, worse in morning/with Valsalva, focal deficits	MRI brain

6. MONITORING PARAMETERS¶

Parameter	ED	HOSP	OPD	ICU	Frequency	Target/Threshold	Action if Abnormal
Pain scale (0-10)	STAT	q4h	Each visit	-	Per assessment	Improving trend	Escalate treatment
Vital signs	STAT	q4h	Each visit	-	Per assessment	Normal	Address abnormalities
ECG (if using DHE/triptans)	STAT	STAT	-	-	Before administration	Normal QTc, no ischemia	Avoid vasoactive drugs
Headache diary	-	Daily	Each visit	-	Ongoing	Reduced frequency	Adjust preventive
MIDAS score	-	-	q3 months	-	Quarterly	Improving disability	Adjust treatment
Medication use tracking	-	ROUTINE	Each visit	-	Ongoing	No overuse	Address MOH

7. DISPOSITION CRITERIA¶

Disposition	Criteria
Discharge from ED	Pain controlled, able to tolerate PO, no red flags, close follow-up arranged
Admit to hospital	Status migrainosus unresponsive to ED treatment, need for DHE protocol, unable to tolerate PO, severe dehydration, concern for secondary headache
ICU admission	Rare - suspected intracranial pathology, hemodynamic instability
Discharge from hospital	Pain controlled on oral medications, tolerating PO, ambulatory
Outpatient follow-up	New diagnosis: 2-4 weeks; Chronic migraine: q1-3 months; On preventive: q3-6 months after stable

8. EVIDENCE & REFERENCES¶

Recommendation	Evidence Level	Source
Triptans effective for acute migraine	Class I, Level A	Cochrane Reviews; AHS Guidelines
Prochlorperazine/metoclopramide effective for acute migraine	Class I, Level A	Friedman et al. Ann Emerg Med 2008; AHS Evidence Assessment 2016
Dexamethasone reduces headache recurrence	Class I, Level A	Singh et al. Acad Emerg Med 2008
DHE effective for status migrainosus	Class II, Level B	Raskin, Neurology 1986
Beta-blockers effective for prevention	Class I, Level A	AAN/AHS Guidelines, Silberstein et al. Neurology 2012
Topiramate effective for prevention	Class I, Level A	AAN/AHS Guidelines, Silberstein et al. Neurology 2012
CGRP mAbs effective for prevention	Class I, Level A	Multiple RCTs; FDA approved 2018+
OnabotulinumtoxinA for chronic migraine	Class I, Level A	PREEMPT pooled analysis, Dodick et al. 2010; Aurora et al. Cephalalgia 2010
Gepants effective for acute and preventive treatment	Class I, Level A	Multiple RCTs 2019-2023
Avoid medication overuse	Class II, Level B	ICHD-3, Cephalalgia 2018

NOTES¶

Migraine is a clinical diagnosis; imaging indicated only for red flags or atypical features
Treat early - medications more effective when taken at onset
Medication overuse is common cause of chronic daily headache; taper offending agents
Consider preventive therapy if ≥4 migraine days/month, significant disability, or acute medications ineffective/overused
CGRP antagonists (gepants and mAbs) are first-line options without cardiovascular contraindications
Triptan cardiovascular contraindications are based on theoretical risk; reassuring real-world data for many patients
Pregnancy: Acetaminophen, metoclopramide, and nerve blocks are safest; discuss triptan use case-by-case

CHANGE LOG¶

v1.0 (January 29, 2026) - Initial template creation - Comprehensive acute and preventive treatment options - Added CGRP antagonists (gepants) and monoclonal antibodies - DHE protocol with prerequisites - Pregnancy-safe options section - Status migrainosus "headache cocktail" protocol