Diagnosis and Treatment of Headache Migraine Treatment Algorithm

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Diagnosis and Treatment of Headache Migraine Treatment Algorithm Powered By Docstoc
					Source: Institute for Clinical Systems Improvement (ICSI). Diagnosis and treatment of headache. Bloomington (MN): Institute for Clinical Systems
Improvement (ICSI); 2007 Jan. 72 p.


                                             Diagnosis and Treatment of Headache
                                                 Migraine Treatment Algorithm
                                                                                                              27
                                                                                                    Patient meets criteria                                        The patient would enter this
                                                                                                         for migraine                                             algorithm from box 17 of the
                                                                                                                               A                                  Diagnosis Algorithm.

                                                                                                              28
                                                                                                                                                       29
                                                                                                           Is patient
                                                                                                                                    no        Return to Diagnosis
                                                                                                        experiencing a
                                                                                                                                                   Algorithm
                                                                                                      typical headache?
                                                                                                                                               Out of guideline

                                                                                                              A
                                                                                                                   yes

                                                                                                             30
                                                                                   Categorize according to peak severity based
                                                                                      on functional impairment, duration of
                                                                                     symptoms, and time to peak impairment
                                                                                                                                         A




                                                31                                       35                              38                                                             43

                                                Mild                               Moderate                           Severe                                                          Status
                                                                                                                                                                                (>72 hour duration)
                                                                                                                                                                                                   A

                                                32                                    36                                 39                                                             44

                                        Mild treatment:**                      Moderate                       Severe                                                            Adjunctive therapy
                                         - APAP / ASA /                        treatment:**                    - Prochlorperazine
                                           Caffeine                              - DHE                         - Chlorpromazine                                                                    A
                                         - ASA                                   - Ergotamine                  - DHE
                                         - Lidocaine nasal                         tartrate                    - Ketorolac IM
                                         - Midrin ®                              - Lidocaine nasal             - Magnesium
                                         - NSAIDs                                - Midrin ® and                  Sulfate IV                            45                                                             47
                                         - 5 HT agonists                           others                      - 5 HT agonists                                                                               Chlorpromazine
                                           (triptans)                            - NSAIDs                        (triptans)                                                                                  Valproate sodium IV
                                                                                                                 See treatment                   Patient meets             no                                Magnesium
                                           Almotriptan                           - 5 HT agonists
                                                                                                                 in #32                         criteria for DHE?                                            Sulfate IV or
                                           Eletriptan                              (triptans)
                                           Frovatriptan                            See treatment                                                                                                             Prochlorperazine
                                                                                                                                                                                                                                   A
                                           Naratriptan                             in #32                                                               A
                                           Rizatriptan                                                       • Adjunctive drug
                                           Sumatriptan                    • Adjunctive drug                    therapy                                      yes
                                           Zolmitriptan                        therapy               A

                                      • Adjunctive drug
                                        therapy
                                                                A


                                                33                                       37                              40                            46                               48
                                                                no                                    no    yes                                Refer to the DHE                                        yes
                                            Successful?                           Successful?                       Successful?                Protocol algorithm                  Successful?

                                                  A                                       A                                                                                             A
                                                      yes                                     yes                             no                                                             no
                                                                                                                                                                                        49

                                                                                                                                                                                     Opiates
                                                                                                                                                                                                   A


                                                                                                                         41                                                             50
                                                                                                                      Specialty          no                                                            yes
                                                                                                                    consultation                                                   Successful?
                                                                                                                     indicated?

                                                                                                                                                                                             no
                                                                                                                              yes
                                                                                                                                                                                        51
                                                                                                                                                                                 Dexamethasone

                                                                                                                                                                                                   A


                                                                                                                                                                                        52
                                                                                                                     42
                                                                                                               Consultation with                                           no
                                                                                                              headache specialist                                                  Successful?
                                                                                                                               A

                                                                     34                                                                                                                      yes

                               54                           Headache resolved
                     Refer to:
                     • Menstrual-Associated
                       Migraine algorithm
                     • Perimenopausal or                             53
                       Menopausal Migraine                                                                                                                    Adjunctive therapy 32, 36, 39, 44
                       algorithm                      yes         Is this a                                                                                   • Rest in quiet, dark room
                     • On Estrogen-Containing                 hormone-related                                                                                 • IV rehydration
                       Contraceptives or                         migraine?                                                                                    • Antiemetics **
                       Considering Estrogen-                                                                                                                    - Hydroxyzine
                       Containing                                         no                                                                                    - Metoclopramide
                       Contraceptives with                                                                                                                      - Prochlorperazine
                       Migraine Algorithm                             55                                                                                        - Promethazine
                                                                  Is patient                              56                                                  • Caffeine
                                                                                         no
                                                                candidate for                       Continue acute
                                                                prophylactic                          treatment
                                                                 treatment?

                                                                       yes
                                                                      57
                                                            Refer to the Migraine
                                                                Prophylactic
                                                            Treatment algorithm
                           A = Annotation



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