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Practice Buzz: How do you manage chronic migraine that presents in an acute care setting?

While recognizing each case is different, please choose the answer that best reflects your common practice and limit free text to strategies that are not included.

Estimated Time: 2 Minutes

CASE
An 18-year-old woman with known migraine without aura history presents to the Emergency Department with headaches similar to her previous migraines, except they have persisted for more than 72 hours. Additionally, she had several episodes of emesis. She does not take any daily medications. She has tried ibuprofen and sumatriptan (more than 24 hours prior to presentation) without relief. Currently, her headache severity is rated at 9/10. Her weight is 70kg and her BMI is 22. Her general and neurologic exams are normal. Her head CT is normal.
1. What would be your first-line treatment? If you would use a combination of medications, select all that apply. *This question is required.

Metoclopramide, prochlorperazine, or chlorpromazine - Route of administration:

*This question is required.
This question requires a valid number format.
Non-steroidal anti-inflammatories - Route of administration: *This question is required.
This question requires a valid number format.
Triptans - Route of administration: *This question is required.
This question requires a valid number format.

Dexamethasone or methylprednisolone - Route of administration:

*This question is required.
This question requires a valid number format.
Diphenhydramine - Route of administration: *This question is required.
This question requires a valid number format.

Valproic acid - Route of administration:

*This question is required.
This question requires a valid number format.
Magnesium sulfate - Route of administration: *This question is required.
This question requires a valid number format.
Dihydroergotamine - Route of administration: *This question is required.
This question requires a valid number format.
Opioids (including tramadol) - Route of administration: *This question is required.
This question requires a valid number format.
CGRP antagonists - Route of administration: *This question is required.
This question requires a valid number format.

Lasmiditan - Route of administration:

*This question is required.
This question requires a valid number format.
This question requires a valid number format.
This question requires a valid number format.
This question requires a valid number format.
2. You reassess the patient 2 hours after the first-line intervention and she reports that her headache is still present and has not changed in severity. What would be your second-line treatment? If you would use a combination of medications, select all that apply. *This question is required.

Metoclopramide, prochlorperazine, or chlorpromazine - Route of administration

*This question is required.
Non-steroidal anti-inflammatories - Route of administration: *This question is required.
Triptans - Route of administration: *This question is required.
This question requires a valid number format.

Dexamethasone or methylprednisolone - Route of administration:

*This question is required.
This question requires a valid number format.
Diphenhydramine - Route of administration: *This question is required.
This question requires a valid number format.

Valproic acid - Route of administration:

*This question is required.
This question requires a valid number format.
Magnesium sulfate - Route of administration: *This question is required.
This question requires a valid number format.
Dihydroergotamine - Route of administration: *This question is required.
This question requires a valid number format.
Opioids (including tramadol) - Route of administration: *This question is required.
This question requires a valid number format.
CGRP antagonists - Route of administration: *This question is required.
This question requires a valid number format.

Lasmiditan - Route of administration:

*This question is required.
This question requires a valid number format.
This question requires a valid number format.
This question requires a valid number format.
This question requires a valid number format.
3. What are your ED discharge criteria for this patient? Of note, at baseline, she is headache-free. Choose all that apply. *This question is required.
4. The patient reports that her headache is now at 10/10. You admit her for inpatient management. What interventions would you use first to treat her headaches in an inpatient setting? If you would use a combination, select all that apply.
  • * This question is required.

Metoclopramide, prochlorperazine, or chlorpromazine - Route of administration:

*This question is required.
This question requires a valid number format.
This question requires a valid number format.
Non-steroidal anti-inflammatories - Route of administration: *This question is required.
Triptans - Route of administration: *This question is required.
This question requires a valid number format.
This question requires a valid number format.

Dexamethasone or methylprednisolone - Route of administration:

*This question is required.
This question requires a valid number format.
This question requires a valid number format.
Diphenhydramine - Route of administration: *This question is required.
This question requires a valid number format.
This question requires a valid number format.

Valproic acid - Route of administration:

*This question is required.
This question requires a valid number format.
This question requires a valid number format.
Magnesium sulfate - Route of administration: *This question is required.
This question requires a valid number format.
This question requires a valid number format.
Dihydroergotamine - Route of administration: *This question is required.
This question requires a valid number format.
This question requires a valid number format.
Opioids (including tramadol) - Route of administration: *This question is required.
This question requires a valid number format.
This question requires a valid number format.
CGRP antagonists - Route of administration: *This question is required.
This question requires a valid number format.
This question requires a valid number format.

Lasmiditan - Route of administration:

*This question is required.
This question requires a valid number format.
This question requires a valid number format.
This question requires a valid number format.
This question requires a valid number format.
This question requires a valid number format.
This question requires a valid number format.
This question requires a valid number format.
This question requires a valid number format.
5. After inpatient management, her headache remits and she is discharged home. You continue to follow her in an outpatient setting. She continues to have severe headaches (7-9/10) twice a week causing her to miss work. You decide to start a preventive medication. She tried propranolol, amitriptyline, verapamil, topiramate, and cognitive behavioral therapy without significant improvement. What would you try next as a preventive treatment for her migraines? Rank your top 3 choices. *This question is required. Note: for the following table each column is restricted to a single answer across all rows.
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6. In your practice, which of the following methods of neuromodulation have you used for headache prevention? Select all that apply. *This question is required.