Migraine : Acute remote triage

Migraine is a common and debilitating neurological disorder characterized by severe, recurrent headaches often accompanied by nausea, vomiting, photophobia, and phonophobia (Pasula et al., 2020; Ahmed et al., 2023).
It ranks second globally in terms of disease burden, significantly contributing to years lived with disability (Davidsson et al., 2021).
Lifetime prevalence is estimated at 11.7%, affecting millions annually (Davidsson et al., 2021).
Many patients report unmet treatment needs, emphasizing the necessity for improved acute and preventive management strategies (Zhao et al., 2023).

📌 First-Line Treatment for Acute Migraine

NSAIDs (e.g., ibuprofen, naproxen) and triptans (e.g., sumatriptan, rizatriptan) are first-line pharmacological options (Tepper et al., 2021).
Early administration of these medications improves effectiveness, reducing the duration and severity of attacks (Worthington et al., 2013).
Challenges with acute treatments include ineffectiveness, poor tolerance, and risk of medication overuse headache (MOH) (Pasula et al., 2020; Martelletti et al., 2018).

Headache Red Flag Checklist

🔍 Acute Headache Triage – Red Flag Checklist

🚨 Select any red flags that apply. If any are checked, urgent evaluation is required.

Headache Characteristics

🧠 Section 2: Headache Characteristics

Gather detailed information to assess if the headache follows a typical migraine pattern or indicates something unusual.

2.1 When did the headache start?

2.2 How did the headache start?

2.3 How long has this headache lasted?

2.4 Is the pain constant or does it come and go?

2.5 Where is the head pain located?

2.6 How would you describe the pain?

2.7 On a scale of 0 to 10, how severe is the pain?

2.8 What makes the headache worse?

2.9 What makes the headache better?

Associated Symptoms & Auras

🌟 Section 3: Associated Symptoms and Auras

Assess migraine-related symptoms and potential headache triggers.

Migraine History and Pattern

🧠 Section 4: Migraine History and Pattern

Assess past migraine history and any changes in headache patterns.

4.1 Have you had similar headaches diagnosed as migraines?

4.2 How many years have you had migraine headaches?

4.3 How often do you get these headaches?

4.4 Is this headache similar to your usual migraines?

4.5 Have you noticed recent changes in your headache pattern?

4.6 Is there a family history of migraines?

Current Treatment and Response

💊 Section 5: Current Treatment and Response

Assess what treatments have been attempted and their effectiveness.

5.1 What treatments have you tried for this headache?
No treatment taken yet
Over-the-counter pain reliever (paracetamol, ibuprofen, aspirin)
Prescription migraine medication (sumatriptan, rizatriptan, etc.)
Other prescription pain medication (NSAID, opioid, steroid)
Anti-nausea medication (oral or suppository)
Caffeine (coffee/tea) or combination analgesic with caffeine
Non-drug measures (dark room, ice pack, hydration, relaxation techniques)
Other remedies

5.2 How has the headache responded to treatment?

5.3 How soon after headache onset did you take the medication?

5.4 If no or partial relief: Were you able to keep fluids and medicine down?

5.5 If headache improved, are you still pain-free?

5.6 Any side effects or issues with the medication?

5.7 What usually works best for your migraines?

Issues with Medication Overuse & Inadequate Prophylaxis

MOH is a major concern when acute medications (especially triptans and analgesics) are overused, leading to chronic migraine (Martelletti et al., 2018).
Many patients lack access to preventive treatments, even though they could reduce migraine frequency and severity (Woolley et al., 2017; Katsarava et al., 2018).
Studies show that patients often combine over-the-counter (OTC) medications with prescribed therapies, necessitating careful treatment evaluation (Buse et al., 2015).

Primary Care Role in Migraine Management

Timely intervention and appropriate treatment selection are critical to effective acute migraine management (Worthington et al., 2013; Becker, 2015).
Primary care providers must:
- Monitor adherence to prescribed treatments.
- Minimize medication misuse to prevent chronic migraine.
- Adjust treatment plans based on efficacy, tolerability, and patient preference (Tepper et al., 2021; Kim et al., 2022).
Addressing barriers to effective treatment—such as side effects, inadequate relief, or risk of MOH—is essential for optimizing patient outcomes (Zhao et al., 2023).

For acute management please see : https://a4medicine.co.uk/chart/details/Migraine_:_Acute_management+671023bb59e66b23b1f0e527

Triage Decision and Treatment Plan

🩺 Triage Decision and Treatment Plan

Category	Criteria	Next Steps
🚨 Immediate Emergency Evaluation	- Any red flag symptoms (neurologic deficits, thunderclap onset, fever, neck stiffness, confusion, seizure, vision loss). - Severe or sudden-onset headache with possible secondary cause (e.g., stroke, meningitis, hemorrhage).	Send to ER immediately – urgent imaging, specialist evaluation, do not delay care.
⚠️ Urgent Office Visit / Further Workup	- No immediate emergency red flags but headache pattern has changed or it’s the first severe headache of this type. - Symptoms suggest secondary headache (e.g., new onset in older adult, progression over weeks).	Same-day or next-day appointment for focused examination and possible neuroimaging.
💊 Acute Treatment Adjustment	- Likely migraine, but current medication is ineffective or poorly tolerated. - Incomplete symptom relief despite OTC or prescription medications.	Modify treatment plan: - Consider different triptan, NSAID, or combination therapy. - Add an anti-emetic if nausea is preventing oral medication use. - Consider steroids (one-time dose for prolonged migraine). - Ensure proper dosing & early administration.
🏡 Conservative Management & Reassurance	- Headache is consistent with a typical migraine. - No red flags, patient has a history of similar episodes. - Symptoms already improving or manageable at home.	Provide home-care advice: - Rest in a dark, quiet room. - Hydration, small light meal if tolerated. - Cold packs, relaxation techniques. - Take prescribed medication as directed. - Monitor for worsening symptoms and seek care if needed.
🔄 Follow-Up & Preventive Plan	- Frequent migraines (≥4 headache days/month). - Evolving pattern requiring ongoing assessment. - Patient at risk for medication overuse headache (MOH).	Schedule follow-up (2–8 weeks): - Discuss preventive strategies (daily meds, lifestyle changes, trigger management). - Ensure effective acute treatment plan. - Consider neurology referral for severe, refractory, or uncertain cases.

Acute Treatment Recommendations

📌 Acute Treatment Recommendations

Medication Type	Options	Considerations
First-Line Simple Analgesics	- Ibuprofen 400–600 mg - Aspirin 900 mg - Paracetamol 1000 mg	- Take at migraine onset. - Combine with caffeine for better effect.
Triptans (First Choice for Migraine-Specific Therapy)	- Sumatriptan 50–100 mg (oral) - Alternative triptans if ineffective	- Take only at headache onset, NOT during aura. - Combine with NSAID (e.g., naproxen) for enhanced effect.
Non-Oral Triptan Options (If Vomiting Prevents Oral Use)	- Sumatriptan nasal spray / injection - Rizatriptan sublingual	- Consider for patients with nausea/vomiting.
Anti-Emetics (Adjunctive Treatment)	- Metoclopramide 10 mg - Prochlorperazine 10 mg	- Helps relieve nausea and improve drug absorption. - Avoid frequent use of metoclopramide due to risk of extrapyramidal side effects.
Avoid These Medications	- Opioids - Ergots	- Risk of dependency & medication overuse headache.

📌 References

Ahmed, U., Saleem, M., Osman, M., & Shamat, S. (2023). Novel FDA-approved zavegepant drug for treating migraine. Annals of Medicine and Surgery, 86(2), 923-925. https://doi.org/10.1097/ms9.0000000000001620
Becker, W. (2015). Acute migraine treatment in adults. Headache: The Journal of Head and Face Pain, 55(6), 778-793. https://doi.org/10.1111/head.12550
Buse, D., Serrano, D., Reed, M., Kori, S., Cunanan, C., Adams, A., … & Lipton, R. (2015). Adding additional acute medications to a triptan regimen for migraine and observed changes in headache‐related disability: Results from the American Migraine Prevalence and Prevention (AMPP) study. Headache: The Journal of Head and Face Pain, 55(6), 825-839. https://doi.org/10.1111/head.12556
Davidsson, O., Olofsson, I., Kogelman, L., Andersen, M., Rostgaard, K., Hjalgrim, H., … & Hansen, T. (2021). Twenty-five years of triptans – A nationwide population study. Cephalalgia, 41(8), 894-904. https://doi.org/10.1177/0333102421991809
Katsarava, Z., Mania, M., Lampl, C., Herberhold, J., & Steiner, T. (2018). Poor medical care for people with migraine in Europe – Evidence from the Eurolight study. The Journal of Headache and Pain, 19(1). https://doi.org/10.1186/s10194-018-0839-1
Kim, J., Lee, S., & Rhew, K. (2022). Association between gastrointestinal diseases and migraine. International Journal of Environmental Research and Public Health, 19(7), 4018. https://doi.org/10.3390/ijerph19074018
Martelletti, P., Schwedt, T., Lantéri‐Minet, M., Quintana, R., Carboni, V., Diener, H., … & Vo, P. (2018). My Migraine Voice Survey: A global study of disease burden among individuals with migraine for whom preventive treatments have failed. The Journal of Headache and Pain, 19(1). https://doi.org/10.1186/s10194-018-0946-z
Pasula, D., Thankachan, L., Rao, D., & Prasad, D. (2020). A comprehensive study on Nerivio Migra. World Journal of Current Medical and Pharmaceutical Research, 02(01), 30-32. https://doi.org/10.37022/wjcmpr.2020.020110
Tepper, S., Fang, J., Vo, P., Shen, Y., Zhou, L., Abdrabboh, A., … & Ferraris, M. (2021). Impact of erenumab on acute medication usage and healthcare resource utilization among migraine patients: A US claims database study. The Journal of Headache and Pain, 22(1). https://doi.org/10.1186/s10194-021-01238-2
Woolley, J., Bonafede, M., Maiese, B., & Lenz, R. (2017). Migraine prophylaxis and acute treatment patterns among commercially insured patients in the United States. Headache: The Journal of Head and Face Pain, 57(9), 1399-1408. https://doi.org/10.1111/head.13157
Worthington, I., Pringsheim, T., Gawel, M., Gladstone, J., Cooper, P., Dilli, E., … & Becker, W. (2013). Introduction to the guideline, and general principles of acute migraine management. Canadian Journal of Neurological Sciences, 40(S3), S4-S9. https://doi.org/10.1017/s0317167100118955
Zhao, H., Xiao, Z., Zhang, L., Ford, J., Zhong, S., Ye, W., … & Chen, C. (2023). Real-world treatment patterns and outcomes among patients with episodic migraine in China: Results from the Adelphi Migraine Disease Specific Programme™. Journal of Pain Research, Volume 16, 357-371. https://doi.org/10.2147/jpr.s371887
National Institute for Health and Care Excellence (NICE). Migraine: Management in adults. https://cks.nice.org.uk/topics/migraine/management/adults/