Migraine Headache Clinical Pathway — Emergency Department

Additional Testing: New/Worsening Headache

Consider need for these tests in the following scenarios:

New-onset Migraine
  • (in all patients)
Chronic Migraine
  • (if not already completed, especially if onset of constant headache was not preceded by frequent episodic migraine)
Episodic Migraine
  • (if significant recent change in HA)
  • Brain MRI with and without contrast
  • Add MRA if concern for aneurysm
    (pulsatile tinnitus, family history, stereotyped aura)
Consider Ophthalmology consult
  • Definite papilledema: Consult Neuro-ophthalmology
  • Possible papilledema: Consult Ophthalmology
  • Orthostatic heart rate and blood pressure changes
    Have patient still and quiet, minimize distractions and discourage conversation while checking vital signs, as anxiety may affect heart rate.
  • Procedure:
  • Lying down
  • After 3 minutes of being relaxed:
    • Check HR and BP
  • Standing
  • Hands at side, no support:
    • 3 minutes: check HR & BP
    • 5 minutes: check HR
    • 7 minutes: check HR
    • 10 minutes: check HR
  • Positive result for POTS (vs. orthostatic hypotension):
  • HR change of ≥ 30 bpm or a threshold HR ≥ 120 bpm
  • CBC
  • CMP
  • Vitamin B2 (Riboflavin) and Vitamin D25OH
  • TSH, Free T4
  • ESR, CRP
  • Lyme titer with reflexive western blot
  • EBV antibodies (looking for cause of new-onset headache only, would not treat)
  • PPD if risk factors for tuberculosis
  • Consider ANA if arthritis, fatigue, rash
  • Consider celiac panel IgA (add IgG only if IgA deficient), esp if GI symptoms
  • Consider AM cortisol and ACTH, if > 30 beat pulse change on orthostatic vital signs or persistent tachycardia
Consider LP:
  • Head imaging precedes this if focal exam, concern for increased ICP
  • Measure opening pressure in lateral recumbent position
  • Cell count (1st, 4th tubes), glucose, protein, gram stain, culture, save specimen
    • If abnormal consider ID consult and consider sending: Lyme, HSV, Enterovirus, Parechovirus, and LCMV PCRs from CSF, and Ehrlichia panel, Babesia IgG, and Malaria Smear from blood. If lymphocytic pleocytosis give IV Acyclovir until HSV PCR is negative
  • If OP > 20, drain CSF until closing pressure is 10-20 and evaluate if symptoms improve (HA, pulsatile tinnitus, visual)
  • If patient's symptoms improve or if OP > 28 consider treating for pseudotumor
  • Positional post-LP headache does not exclude the diagnosis of pseudotumor
Considerations for Performing an LP