MDM - Migraine Headache

[##]-year-old [male/female] with headache with history and exam consistent with likely migraine.

Initial consideration in this patient included migraine, cluster headache, tension headache, meningitis, encephalitis, subarachnoid hemorrhage (SAH), venous sinus thrombosis, and intracranial hemorrhage or tumor among others.  

Patient presented with headache suggestive of likely migraine based on [headache lasting 4-72 hours with unilateral location, pulsating quality, moderate to severe pain intensity and avoidance of routine physical activity with associated nausea and/or vomiting, photophobia, and phonophobia].  Patient noted to have a normal neurologic exam without report of preceding trauma.  Patient [did/did not] describe associated aura suggestive of typical migraine.  Patient reported onset of headache was gradual, with no report of headache that was maximal at onset or thunderclap in nature.  Doubt subarachnoid hemorrhage at this time.  No fever, evidence of meningismus, or systemic infectious symptoms suggestive of meningitis or encephalitis at this time.  

Neuroimaging was felt to [not be indicated at this time based on normal neurologic exam in patient with headache with features suggestive of migraine/obtained in this patient due to report of headache that differs in character from prior migraines/other concerning feature(s)].  After discussion of available options for treatment [the patient was given Metoclopramide (Reglan)/Prochlorperazine (Compazine)/Haloperidol (Haldol)/Dexamethasone (Decadron) with Diphenhydramine (Benadryl)/Ketorolac (Toradol)/Acetaminophen (Ofirmev)/a sphenopalantine ganglion (SPG) block/a greater occipital nerve (GON) block].  Patient reported significant improvement with treatment prior to discharge from ED.

Prior to discharge, we discussed return precautions, specifically for evidence of worsening headache or neurologic deficits, symptomatic treatment, and follow up with primary care doctor within [2-3 days/1 week] for further evaluation and consideration of possible imaging or referral to Neurology, and the patient demonstrated understanding and agreement.

https://www.aliem.com/trick-sphenopalatine-ganglion-block-primary-headaches/
http://www.emdocs.net/pain-profiles-ed-migraine-management-the-new-kid-on-the-block/