Skill Checkup: A 20-Year-Old Woman With a Diffuse Pulsatile Headache, Neck Pain, and Nausea

Helmi L. Lutsep, MD


February 10, 2022

Treatment of migraines is often associated with a trial-and-error period. Critically, criteria for initiating acute treatment with gepants, ditans, or neuromodulatory devices specify that the patient is at least 18 years of age, with either contraindications, an inability to tolerate, or an inadequate response to two or more oral triptans. Therefore, this patient may benefit from trying another oral triptan before exploring other treatment options.

If acute treatment is ineffective, some patients may require rescue medication.

Depending on the initial treatment, outpatient rescue options include subcutaneous sumatriptan, intramuscular dihydroergotamine (DHE) or intranasal spray, intramuscular ketorolac, or corticosteroids, whereas inpatient options include parenteral formulations of triptans, DHE, antiemetics, NSAIDs, anticonvulsants (though not for women who are or may become pregnant), and corticosteroids. Intravenous DHE and an antiemetic should be considered for especially refractory headaches.

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