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 Additional Information: CHOP Nursing Policy for Orthostatic Blood Pressure Measurement, 4:1:E (Not POTS specific)
	Labs: 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

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The clinical pathways are based upon publicly available medical evidence and/or a consensus of medical practitioners at The Children’s Hospital of Philadelphia (“CHOP”) and are current at the time of publication. These clinical pathways are intended to be a guide for practitioners and may need to be adapted for each specific patient based on the practitioner’s professional judgment, consideration of any unique circumstances, the needs of each patient and their family, and/or the availability of various resources at the health care institution where the patient is located.

Accordingly, these clinical pathways are not intended to constitute medical advice or treatment, or to create a doctor-patient relationship between/among The Children’s Hospital of Philadelphia (“CHOP”), its physicians and the individual patients in question. CHOP does not represent or warrant that the clinical pathways are in every respect accurate or complete, or that one or more of them apply to a particular patient or medical condition. CHOP is not responsible for any errors or omissions in the clinical pathways, or for any outcomes a patient might experience where a clinician consulted one or more such pathways in connection with providing care for that patient.