Key Points
- Stabilize ABCs; begin targeted evaluation without delaying life-saving therapy.
- Use system-specific risk tools to guide testing and disposition.
- Order high-yield tests first; escalate imaging when indicated.
- Start evidence-based initial therapy and reassess frequently.
Algorithm
- Primary survey and vitals; IV access and monitors.
- Focused history/physical; identify red flags and likely etiologies.
- Order system-appropriate labs and imaging (see Investigations).
- Initiate guideline-based empiric therapy (see Pharmacology).
- Reassess response; arrange consultation and definitive management.
Clinical Synopsis & Reasoning
For Chronic Migraine Preventive Therapies Cgrp, frame the differential by acuity and pathophysiology, then align diagnostics to the leading hypotheses. Prioritize stabilization while obtaining high‑yield studies such as CT Head (NC) (Hemorrhage exclusion), Glucose (POC) (Exclude hypoglycemia), MRI Brain (selected) (Ischemia/structural). Incorporate bedside imaging and targeted labs to define severity and identify complications; synthesize results with clinical trajectory to refine the working diagnosis and disposition needs.
Treatment Strategy & Disposition
Initiate disease‑directed therapy alongside supportive care, titrating to objective response. Pharmacologic options commonly include Thrombolytic (eligible), Antiepileptics. Use validated frameworks (e.g., Preventive Options — Examples) to guide escalation and site of care. Address precipitating factors, de‑escalate empiric therapies with data, and arrange follow‑up for monitoring and risk‑factor modification; admit patients with instability, high risk of deterioration, or needs for close monitoring.
Management Notes
Limit acute medications to ≤2–3 days/week to avoid medication‑overuse headache. Combine pharmacologic prevention with sleep hygiene, hydration, and stress reduction.
Epidemiology / Risk Factors
- Hypertension, AF, atherosclerosis; prior stroke/TIA
Investigations
| Test | Role / Rationale | Typical Findings | Notes |
|---|---|---|---|
| CT Head (NC) | Hemorrhage exclusion | Acute blood | First-line |
| Glucose (POC) | Exclude hypoglycemia | Low | Treat promptly |
| MRI Brain (selected) | Ischemia/structural | Diffusion restriction |
Preventive Options — Examples
| Class | Example | Notes |
|---|---|---|
| Antiepileptic | Topiramate | Weight loss, paresthesias |
| Beta‑blocker | Propranolol | Avoid in asthma |
| TCA | Amitriptyline | Sedation, anticholinergic |
| CGRP mAb | Erenumab/fremanezumab | Monthly/quarterly dosing |
| Botulinum toxin | OnabotulinumtoxinA | Every 12 weeks |
Pharmacology
| Medication | Mechanism | Onset | Role in Therapy | Limitations |
|---|---|---|---|---|
| NSAID + metoclopramide | COX inhibition + D2 blockade | Minutes | First-line acute therapy | GI/akathisia |
| Triptan | 5-HT1B/1D agonist | Minutes | Moderate-severe attacks | Contra CAD/stroke |
Prognosis / Complications
- Outcome tied to time-to-reperfusion; aspiration/DVT risks
Patient Education / Counseling
- Explain red flags and when to seek emergent care.
- Reinforce medication adherence and follow-up plan.
References
- AHS Consensus — CGRP/OnabotulinumtoxinA — Link