Ancillary testing

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a. Neuroimaging (CT or MRI scan). Consider for all patients with headache. If patient has normal findings on exam and has only a history of headache, neuroimaging study is not needed emergently. MRI scan is more sensitive than CT but requires that patient remain still for a prolonged period of time, and therefore often requires sedation.

b. Sinus x-ray or CT imaging. If clinically indicated.

c. EEG. The gold standard for seizures; can demonstrate cerebral cortical dysfunction due to generalized encephalopathy or localized destructive or space-occupying lesion.

d. ECG. If a cardiac disorder is suspected.

V. Plan. ABCs must be assessed in any clinical setting. A next, crucial step is to determine if a specific clinical condition requires emergency intervention, urgent management, or routine care.

A. Emergency Management. If patient was having active vomiting with signs of dehydration or increased intracranial pressure, emergent medical or surgical management may be required. Migraine can progress to status migrainosus. IV medication may be required for this condition.

1. During status migrainosus, establish IV access and obtain appropriate blood tests.

2. Administer medications. Possible agents include:

a. Prochlorperazine, 5-10 mg, or metoclopramide, 10 mg IV.

b. DHE, 0.5-1 mg IV. If headache persists for 30 minutes, repeat 0.5 mg IV; can be repeated q8h until headache clears. DHE should not be used in patients with peripheral vascular or coronary artery disease, hypertension, renal or hepatic failure, hyperthyroidism-complicated migraines, or pregnancy.

d. Dexamethasone, 4 mg IV.

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