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Migraine and undifferentiated headache
SOHAN PAREKH AND ANDY JAGODA
n Agents
n Ergots
n Antiemetics
n Triptans
n NSAIDs
n Opioids
n Steroids
n Evidence
The ED physician frequently encounters patients with migraine headache
(MH). Many patients have carried the diagnosis for years, but in some cases
there may be uncertainty as to the precise type of cephalalgia present. In fact,
in the ED population, about a third of patients with headache cannot be
precisely differentiated. 1 Other chapters address other headache etiologies,
but the ED physician should be reassured by acute care literature demonstrating
that headache type differentiation is not always necessary for successful
treatment. If patients have uncertain etiology, or other headache
etiologies besides those covered in other chapters in this text, the acute
care provider may find the “anti-migraine” therapies useful. 2 This recommendation
assumes the ED physician administers disease-specific treatments
where appropriate (e.g. corticosteroids for tumor-related swelling,
decongestants for sinusitis).
The ergot alkaloids, available in myriad formulations, are among the
oldest drugs used for MH. Data addressing efficacy of the oldest such
agent, ergotamine, is mixed at best. Ergotamine exhibits inconsistent efficacy
in numerous studies of varying methodological rigor; the overall picture
from available evidence is one of doubtful efficacy (and no ED role) for
ergotamine. 3,4
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