Test Your Knowledge of Urgent Care Management of Migraine and Other Primary Headaches (Postscript 2 of 2)

Evidence-Based Urgent Care Postscript
Urgent Care Management of Migraine and Other Primary Headaches (Pain Management CME and Pharmacology CME) | May 2025

A 28-year-old G1P0 woman at 32 weeks’ gestation presents to urgent care with a severe, throbbing headache that started 6 hours ago. She describes the pain as 9/10 in intensity, located primarily in the frontal and occipital regions, not relieved by oral acetaminophen. She also reports photophobia, nausea, and 1 episode of vomiting. She denies visual aura, trauma, or recent illness. She has a history of migraines, but notes that this headache feels “different and worse than usual.” She reports decreased fetal movement over the past few hours. On physical examination, her vitals are blood pressure 172/110 mmHg; heart rate 92 bpm; respiratory rate 18 breaths per min; temperature 98.7˚ F; and SpO2 98% on room air. Fetal heart rate is around 110 beats per min, audible but sluggish, and the rest of her physical examination is normal.

Which of the following findings most strongly indicates the need for emergent ED referral?

  1. History of migraines
  2. Nausea and photophobia
  3. Elevated blood pressure with brisk reflexes and decreased fetal movement
  4. Use of acetaminophen without relief

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