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neuro.migraine.core.v1PRODUCTION
neuro.migraine.core.v1

Migraine

neurologysubacuteadult
Hard-required inputs
0 / 6
Care setting:

Encounter flow

10/12 authored

Canonical 12-phase frame with authored status for this dossier.

Current phase

Frame

Detailed

Confirm primary headache (ICHD-3) — exclude secondary (SAH, GCA, RCVS, CVST, dissection, idiopathic intracranial hypertension) (AAN 2024)

Inputs
0
Actions
0
Advance rule
Set
Advance when

red flags negative

Patient inputs (12)

Age informs DDx (GCA in >50, secondary causes); pregnancy alters drug choice (AAN 2024)

MOH (≥10 d/mo opioid/triptan or ≥15 d/mo simple analgesic) — must withdraw before claiming preventive failure (AAN 2024)

Detect MAOI (triptan interaction), SSRI/SNRI (serotonin syndrome), opioids/butalbital (MOH risk) (AAN 2024)

Defines episodic (<15) vs chronic (≥15) migraine; gates preventive therapy (AAN 2024)

Pregnancy excludes valproate, topiramate, ergots; favours acetaminophen / metoclopramide (AAN 2024)

Triptans + ergots contraindicated in CAD/uncontrolled HTN; gepants/ditans alternative (AAN 2024)

HTN-headache overlap; preventive choice (β-blocker vs candesartan) (AAN 2024)

Baseline before CGRP mAb / gepant; topiramate metabolic acidosis monitoring (AAN 2024)

Pre-treatment for women of reproductive age before topiramate/valproate/CGRP mAb (AAN 2024)

Aura affects CV risk + drug eligibility (triptans + estrogens caution) (AAN 2024)

Number of failed preventive classes drives CGRP mAb / gepant access (AAN 2024)

Beta-blocker preventive titration (AAN 2024)

* = hard-required. Engine cannot meaningfully run until these are filled.

Severity triggers (10)

10 need judgement
  • informationalseveresnoop10_red_flag (AAN 2024)
    Any SNOOP10 red flag (thunderclap, focal deficit, papilloedema, age >50, pregnancy/postpartum, immunocompromised, anticoagulated, post-trauma) (AAN 2024)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereaura_with_persistent_focal_deficit
    Aura with focal deficit lasting >60 min OR new aura pattern (AAN 2024)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverepregnancy_aura_severe_HTN
    Pregnancy + new aura + BP >140/90 OR RUQ pain (AAN 2024)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverehemiplegic_aura
    Hemiplegic migraine — fully reversible motor aura (ICHD-3 1.2.3); familial (FHM with CACNA1A/ATP1A2/SCN1A) or sporadic (SHM)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverebrainstem_aura
    Migraine with brainstem aura (formerly basilar-type) — ≥2 of: dysarthria, vertigo, tinnitus, hyperacusis, diplopia, ataxia, decreased consciousness (ICHD-3 1.2.2)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatestatus_migrainosus
    Migraine attack >72 h despite outpatient Rx (AAN 2024)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatemedication_overuse
    ≥10 d/mo opioid/triptan/combination OR ≥15 d/mo simple analgesic (AAN 2024)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatechronic_migraine_threshold
    Chronic migraine — ≥15 headache days/month for >3 months, ≥8 meeting migraine criteria (ICHD-3 1.3) [PMID 29368949]
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatecgrp_mab_nonresponse_3mo
    CGRP monoclonal antibody preventive therapy with <50% reduction in monthly migraine days at 3 months (AHS 2024 response criterion)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatebp_concern_on_triptan
    Patient on triptan with new uncontrolled HTN (≥140/90 on repeat), known CAD/PVD, or post-MI <30 d — triptan CV contraindication develops or is unmasked
    Trigger could not be auto-evaluated — needs clinician judgement.

Workflow calculators

This dossier does not reference any calculators.

Recommended regimen

Acute attack treatment ladder (AAN 2024)
axis: migraine_acute_rescuestep 1 - Step 1 — Mild-moderate attack (NSAID / acetaminophen)
Selected step "Step 1 — Mild-moderate attack (NSAID / acetaminophen)" — Mild-moderate attack, no nausea, no prior triptan need
  • ibuprofen
    first line
    NSAID
    400–800 mg PO at onset • PO • PRN; max 3 d/week to avoid MOH (max: 2400 mg/day; <10 d/mo to avoid MOH)
    triggers: mild_moderate_attack
    AHS 2025 — high-dose NSAID first-line for mild-moderate; cap days/month to prevent MOH
    rxcui 5640
  • naproxen
    first line
    NSAID
    500–550 mg PO at onset • PO • PRN (max: 1100 mg/day; <10 d/mo)
    Longer half-life; useful for menstrual migraine (AAN 2024)
    rxcui 7258
  • acetaminophen
    add on
    analgesic
    1000 mg PO at onset • PO • PRN (max: 4 g/day)
    triggers: NSAID_contraindicated, pregnancy
    Pregnancy-safe option (AAN 2024)
    rxcui 161

outpatient playbook — drug actions (4)

  1. 1. acute Rx (triptan or gepant) (AAN 2024)
    Sumatriptan 50–100 mg PO; rimegepant 75 mg (AAN 2024) • PO • PRN at attack onset (AAN 2024)
    trigger: Attack onset (AAN 2024)
    Take early in attack (AAN 2024)
  2. 2. CGRP mAb prevention
    Erenumab 70 mg SC monthly; galcanezumab 240 mg load + 120 mg monthly • SC • monthly
    trigger: ≥4 headache days/month + disability (AAN 2024)
    AHS 2024 first-line
  3. 3. Topiramate alternative
    25 mg QHS titrate to 100 mg/d • PO • BID
    trigger: CGRP not available / contraindicated (AAN 2024)
    Traditional preventive (AAN 2024)
  4. 4. OnabotulinumtoxinA
    155 units IM q12 weeks (PREEMPT) • IM • q12 weeks
    trigger: Chronic migraine ≥15 days/month (AAN 2024)
    PREEMPT (AAN 2024)

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: Recurrent unilateral throbbing headache 4–72h (AAN 2024); Visual / sensory / language aura preceding headache (AAN 2024); Photophobia, phonophobia, nausea/vomiting (AAN 2024).

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Migraine** (neuro.migraine.core.v1).
Phenotype framing: ICHD-3 phenotype: episodic vs chronic, with vs without aura, vestibular, hemiplegic, menstrual, status migrainosus (AAN 2024)
Scope: Confirm primary headache (ICHD-3) — exclude secondary (SAH, GCA, RCVS, CVST, dissection, idiopathic intracranial hypertension) (AAN 2024)

No severity triggers fired against current inputs.

Plan

Regimen axis: **Acute attack treatment ladder (AAN 2024)** — step "Step 1 — Mild-moderate attack (NSAID / acetaminophen)".
1. ibuprofen 400–800 mg PO at onset PO PRN; max 3 d/week to avoid MOH (NSAID, first line) — AHS 2025 — high-dose NSAID first-line for mild-moderate; cap days/month to prevent MOH
2. naproxen 500–550 mg PO at onset PO PRN (NSAID, first line) — Longer half-life; useful for menstrual migraine (AAN 2024)
3. acetaminophen 1000 mg PO at onset PO PRN (analgesic, add on) — Pregnancy-safe option (AAN 2024)

Setting playbook (outpatient) — Reduce headache days, improve disability, prevent MOH, optimise comorbidities (AAN 2024)
4. acute Rx (triptan or gepant) (AAN 2024) Sumatriptan 50–100 mg PO; rimegepant 75 mg (AAN 2024) PO PRN at attack onset (AAN 2024) — Attack onset (AAN 2024) (Take early in attack (AAN 2024))
5. CGRP mAb prevention Erenumab 70 mg SC monthly; galcanezumab 240 mg load + 120 mg monthly SC monthly — ≥4 headache days/month + disability (AAN 2024) (AHS 2024 first-line)
6. Topiramate alternative 25 mg QHS titrate to 100 mg/d PO BID — CGRP not available / contraindicated (AAN 2024) (Traditional preventive (AAN 2024))
7. OnabotulinumtoxinA 155 units IM q12 weeks (PREEMPT) IM q12 weeks — Chronic migraine ≥15 days/month (AAN 2024) (PREEMPT (AAN 2024))

Non-pharmacologic actions:
- Sleep hygiene + regular schedule (AAN 2024)
- Hydration + meal regularity (AAN 2024)
- Aerobic exercise 150 min/week (AAN 2024)
- CBT for headache + biofeedback (AAN 2024)
- Trigger identification diary (AAN 2024)
- Treat MOH by withdrawal of overused acute Rx (AAN 2024)

AVOID / contraindication checks:
- Triptans_avoid_in_uncontrolled_HTN_CAD_PVD (AAN 2024)
- Ergots_avoid_in_pregnancy_CV_disease (AAN 2024)
- NSAID_max_<10_d_per_month_to_avoid_MOH (AAN 2024)
- No_routine_opioids_or_butalbital_for_migraine (AAN 2024)
- Lasmiditan_no_driving_for_8h (AAN 2024)
- Topiramate_pregnancy_class_X_consider_LARC (AAN 2024)

Monitoring

Regimen monitoring:
- headache diary days severity (AAN 2024)
- reliever use days per month for MOH (AAN 2024)
- MIDAS HIT-6 q3 months (AAN 2024)
- BP HR on beta-blocker (AAN 2024)
- topiramate metabolic acidosis kidney stones (AAN 2024)

Setting (outpatient) monitoring:
- Headache diary (AAN 2024)
- MIDAS / HIT-6 q3 months (AAN 2024)
- CGRP mAb response at 3 + 6 months (AAN 2024)
- Switch CGRP class if no ≥50% response at 3 months (AAN 2024)

Follow-up plan: Reassess at 3 mo; switch CGRP class if no ≥50% response; lifestyle (sleep/hydration/exercise/CBT for headache); comorbidity treatment (depression/anxiety/obesity) (AAN 2024)
- Close-out criterion: follow-up cadence + lifestyle plan set

Monitoring phase: Headache diary (days/severity), MIDAS q3 mo, CGRP mAb response @ 3 mo + 6 mo, BP/HR on β-blocker, valproate level + LFT, topiramate cognition (AAN 2024)

Disposition

Current setting: outpatient — Reduce headache days, improve disability, prevent MOH, optimise comorbidities (AAN 2024)

Disposition criteria:
- Continue current regimen if ≥50% reduction at 3 months (AAN 2024)
- Switch CGRP class if no response at 3 months (AAN 2024)
- Refer to headache neurology if 2+ preventive failures (AAN 2024)

Escalation triggers (move to higher acuity):
- Status migrainosus >72 h → ED (AAN 2024)
- New thunderclap or focal deficit → ED for SAH/RCVS workup (AAN 2024)
- Worsening despite preventive switch → headache neurology referral (AAN 2024)

Patient Action Plan

**Migraine personal action plan (AAN 2024)**
Personalised values: typical_attack_pattern, preferred_acute_medication, preventive_medication, rescue_medication_if_severe.

**No headache or stable baseline (AAN 2024)** (green):
Triggers:
- No or mild headache
- Function normal
- Acute meds <2 days/week
Actions:
- Take preventive as prescribed every day
- Maintain trigger control: regular sleep, hydration, meals, exercise
- Track in headache diary
- Keep follow-up appointments

**Active migraine attack (AAN 2024)** (yellow):
Triggers:
- Attack onset (early aura or pain) (AAN 2024)
- Pain ≥4/10 with photophobia / nausea
- Function impaired
Actions:
- Take rescue medication (NSAID, triptan, or gepant) at first sign of attack — earlier is better
- Move to quiet, dark, cool environment
- Hydrate; small meal if nausea allows
- May repeat triptan once at 2 h if needed; do NOT exceed daily max
- Use ondansetron / metoclopramide for nausea if prescribed
Contact provider when:
- Attack lasts >24 hours despite acute treatment
- Using rescue meds >2 days/week consistently (MOH risk)
- New aura features or aura without headache

**Medical alert — possible secondary headache or status migrainosus (AAN 2024)** (red):
Triggers:
- Sudden thunderclap "worst-of-life" headache
- New focal weakness, vision loss, speech change, or confusion
- Headache with fever and neck stiffness
- Headache after head injury
- Headache during pregnancy with vision change or RUQ pain
- Headache lasting >72 hours despite treatment (status migrainosus)
Actions:
- Call 911 / go to ED now
- Do NOT take additional triptans / ergots — risk if non-migraine cause
- Bring medication list
Contact provider when:
- Any red-zone trigger — go directly to ED

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [SEVERE] Any SNOOP10 red flag (thunderclap, focal deficit, papilloedema, age >50, pregnancy/postpartum, immunocompromised, anticoagulated, post-trauma) (AAN 2024)
- [SEVERE] Aura with focal deficit lasting >60 min OR new aura pattern (AAN 2024)
- [SEVERE] Pregnancy + new aura + BP >140/90 OR RUQ pain (AAN 2024)

Citations

- ICHD-3 (Olesen Cephalalgia 2018) + AHS 2024 Acute Treatment Consensus + AHS 2021 Preventive Consensus + AHS 2024 Position Statement (CGRP first-line preventive) + PREEMPT (onabotulinumtoxinA in chronic migraine) + ACP 2025 Prevention Guideline + AHS 2025 ED Acute Treatment [PMID:29368949](https://pubmed.ncbi.nlm.nih.gov/29368949/)
- Cited evidence (PMID 34160823) [PMID:34160823](https://pubmed.ncbi.nlm.nih.gov/34160823/)
- Cited evidence (PMID 38466028) [PMID:38466028](https://pubmed.ncbi.nlm.nih.gov/38466028/)
- Cited evidence (PMID 16968852) [PMID:16968852](https://pubmed.ncbi.nlm.nih.gov/16968852/)
- Cited evidence (PMID 30587518) [PMID:30587518](https://pubmed.ncbi.nlm.nih.gov/30587518/)

Last reconciled with current guidelines: 2026-05-26.
References
  • ICHD-3 (Olesen Cephalalgia 2018) + AHS 2024 Acute Treatment Consensus + AHS 2021 Preventive Consensus + AHS 2024 Position Statement (CGRP first-line preventive) + PREEMPT (onabotulinumtoxinA in chronic migraine) + ACP 2025 Prevention Guideline + AHS 2025 ED Acute Treatment — PMID:29368949
  • Cited evidence (PMID 34160823) — PMID:34160823
  • Cited evidence (PMID 38466028) — PMID:38466028
  • Cited evidence (PMID 16968852) — PMID:16968852
  • Cited evidence (PMID 30587518) — PMID:30587518