Reading Part A Text
Migraine: Diagnosis and Management: Texts
Migraine (a primary headache disorder characterised by recurrent episodes of moderate to severe unilateral throbbing pain, often accompanied by nausea, vomiting, and sensitivity to light and sound) is classified according to its clinical features:
- migraine without aura, where headache occurs without preceding neurological symptoms and is the most common subtype
- migraine with aura, where fully reversible focal neurological symptoms (e.g. visual disturbances such as scintillating scotoma, sensory changes, or speech disturbance) precede or accompany the headache, typically lasting 20–60 minutes
- chronic migraine, defined as headache occurring on ≥15 days per month for more than 3 months, with migraine features on at least 8 of those days
Episodes may be precipitated by a range of triggers including hormonal changes (e.g. menstruation), disrupted sleep, dehydration, dietary factors (e.g. caffeine withdrawal, alcohol), emotional stress, and bright or flickering lights.
Assessment and Management of Acute Migraine
Immediate management:
- Move the patient to a quiet, darkened environment and minimise sensory stimulation
- Administer oral analgesia as early as possible in the attack
- Offer an antiemetic if nausea or vomiting is present
Clinical assessment:
- Obtain a full headache history, including onset, duration, frequency and character of pain
- medication history – enquire about current use of analgesics, triptans and any overuse of acute medications (>10–15 days per month)
- Perform standard clinical observations. Examine and record:
- blood pressure, heart rate and temperature
- pain severity using a validated scale (e.g. numerical rating scale 0–10)
- presence and duration of aura symptoms
- Perform neurological examination. Assess:
- level of consciousness and orientation
- cranial nerve function
- limb power, sensation and coordination
- presence of meningism (neck stiffness, photophobia, Kernig’s sign)
Management:
- Administer a triptan (e.g. sumatriptan) if simple analgesia is insufficient; triptans are contraindicated in patients with ischaemic heart disease or uncontrolled hypertension
- Combine analgesia with an antiemetic (e.g. metoclopramide) to improve absorption and control symptoms
- If oral route is unavailable due to vomiting, use subcutaneous or nasal triptan formulations
- Consider intravenous fluids if the patient is dehydrated from prolonged vomiting
- If in doubt whether headache represents a secondary cause, perform urgent imaging and treat as a neurological emergency
- Review preventive therapy need in patients with frequent or disabling attacks
Drug Therapy Protocol:
Authorised Indigenous Health Worker (IHW) must consult Medical Officer (MO) or Nurse Practitioner (NP).
Scheduled Medicines Rural & Isolated Practice Registered Nurse may proceed.
| Drug | Form | Strength | Route | Recommended Dosage | Duration |
|---|---|---|---|---|---|
| Sumatriptan | Tablet | 50 mg / 100 mg | Oral | Adult: 50–100 mg at onset; may repeat after 2 hours if partial response. Max 300 mg/24 hours | Stat; further doses on MO/NP order |
| Injection | 6 mg/0.5 mL | Subcutaneous (IHW may not administer SC without MO/NP order) | Adult: 6 mg SC at onset; may repeat after 1 hour if required. Max 12 mg/24 hours | Stat; further doses on MO/NP order | |
| Aspirin | Dispersible tablet | 900 mg | Oral | Adult: 900 mg at onset (dissolve in water). Not recommended in children <16 years | Stat; further doses on MO/NP order |
| Metoclopramide | Tablet / Injection | 10 mg | Oral / IM / IV (IHW may not administer IV) | Adult: 10 mg up to three times daily; child 1–18 yrs: 0.1–0.15 mg/kg per dose (max 10 mg) | Up to 5 days; further on MO/NP order |
Use lower end of dose ranges in patients ≥65 years or those with hepatic impairment.
Provide Consumer Medicine Information: advise sumatriptan can cause chest tightness, flushing and dizziness.
Medication overuse headache may develop if acute treatments are used on more than 10–15 days per month – warn patients accordingly.
Metoclopramide carries a risk of extrapyramidal side effects, particularly in young patients and the elderly; limit treatment duration.
Technique for subcutaneous sumatriptan administration – use the same principles when administering other subcutaneous agents
- Confirm the patient’s diagnosis, prescribed dose and the absence of contraindications, including ischaemic heart disease, prior stroke, uncontrolled hypertension, or concurrent use of monoamine oxidase inhibitors (MAOIs).
- Select an appropriate injection site – the outer thigh or the abdomen (at least 5 cm from the navel) are preferred. Rotate sites with each administration to prevent lipodystrophy.
- Ensure any tight or restrictive clothing is removed from the chosen injection site before proceeding.
- Clean the skin with an alcohol swab and allow to dry fully before inserting the needle, as wet skin increases the risk of local irritation.
- Using the auto-injector, hold the device firmly against the skin at a 90-degree angle and activate. Maintain firm pressure for 10 seconds after activation to ensure full dose delivery.
- Instruct the patient to remain seated or lying down for at least 20 minutes following injection, as chest tightness or flushing may occur transiently.
- Do not administer a second dose if the patient experiences chest pain or significant chest tightness after the first injection; seek urgent medical review instead.
- After 1 hour, reassess the patient’s pain score, associated symptoms and blood pressure to evaluate response and determine whether a repeat dose is indicated.