Neuroimaging should also be ordered in patients with unilateral headache that always occurs on the same side (side-locked), a feature of trigeminal autonomic cephalalgias, which can be mimicked by underlying central nervous system diseases, such as pituitary tumors, intracranial dissections or aneurysms, and infections.
Magnetic resonance imaging (MRI) is preferred over computed tomography (CT) as it provides better visualization of the brain tissues and is more sensitive in detecting subtle lesions.The use of contrast can further help with visualizing different parts of the the brain and should be considered when intracranial mass, infection, or inflammation are suspected.
For patients with stable headaches who meet criteria for migraine and have a normal neurologic examination are strongly recommended against routine neuroimaging. The detection of incidental findings can trigger undue patient anxiety and unnecessary investigations and procedures.
How to Approach to Acute Treatment of a Migraine Attack
The goal of treatment for migraine attacks is to provide rapid relief from pain and other migraine-related symptoms, to restore patient function and to prevent recurrence. Ideally, treatment should be self-administered, effective, well tolerated and affordable, and require minimal re-dosing.
Migraine attacks associated with mild disability can be treated with simple analgesics, with an additional dose of the same or a different agent in the next 2-24 hours, if needed.
Classic Medicines for Acute Treatments for Migraine
Acetaminophen, acetylsalicylic acid, diclofenac, ibuprofen, naproxen sodium, and triptans have the highest level of evidence for treatment of migraine attacks. Dihydroergotamine, which has been available for decades, can be useful as a first-line agent in some patients (patients with severe attacks or who do not respond well to triptans, or both). However, the use of dihydroergotamine, given potential drug interactions and a high risk of vascular adverse effects.
New Drugs for Acute Treatment of Migraine
Two classes of orally administered small-molecule drugs have recently been approved by the US Food and Drug Administration for the treatment of migraine: ditans and gepants. They can be used in patients with cardiovascular disease, in whom triptans are contraindicated.
- Health care utilization in patients with migraine: demographics and patterns of care in the ambulatory setting – (https://pubmed.ncbi.nlm.nih.gov/12656703/)
- Migraine Headache – (https://www.ncbi.nlm.nih.gov/books/NBK560787/)
- Migraine – (https://www.nhs.uk/conditions/migraine/)
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