What's your favorite migraine treatment in the ER?

[xxbowiexx]

Lets hear it!

[Superfundee]

reglan and toradol !!

[icthus13]

Reglan and toradol here too!

[pahopeful]

Toradol, compazine, benadryl and a liter of NS. Works wonders for true migraneurs.

[jmj11]

I'm a bit curious, and I mean this respectfully as an honest question. The American Headache Society has recommended for about three decades the treatment of choice, at least initially, in the acute setting is an IV neuroleptic plus dihydroergotamine . . . with analgesic add on if needed. However, I virtually never see our local ERs use this combination and I've never understood why. So, from an ER providers' perspective why don't you?

[browndog]

Reglan, toradol, benadryl, n/s bolus. 2 for 2 tonight.

[EMEDPA]

reglan/benadryl +/- toradol.

for those "allergic" to all of the above with no recent narc usage nubain 10/vistaril 25

[Devildog]

Reglan gives them that " I gotta get out of here.." feeling which we all like:wink:

[ventana]

reglan/benadryl +/- toradol.

second that

[jmj11]

I guess I will ask the question again in a different way, why do you think that most ERs ignore the recommended ER treatments as proposed by the American Headache Society and reinvent the wheel on their own? There have been several goo AHS papers written on the treatment of migraine in the ER including protocols that seem have the best results but these are usually ignored by most ERs.

[medic25]

I guess I will ask the question again in a different way, why do you think that most ERs ignore the recommended ER treatments as proposed by the American Headache Society and reinvent the wheel on their own? There have been several goo AHS papers written on the treatment of migraine in the ER including protocols that seem have the best results but these are usually ignored by most ERs.

 

Do you have links to the protocols? I'd suspect a large part of it is a lack of familiarity with the protocols; we don't tend to get a lot of headache literature distributed to the ED's. I think many of us use therapies like reglan, compazine, toradol, etc because A) We are familiar with the drugs and their side effect profiles, and B) because they usually work. I've had excellent success for years with Compazine and/or Reglan with toradol (although the literature I've read supports Compazine over Reglan, so it's usually my first choice). Most of the folks I've worked with are hesitant to go right to ergotamines because of the concern for cardiovascular side effects and severe nausea/vomiting. The few times I've brought up DHE to refractory patients, several of them have told me that they couldn't tolerate the way it made them feel.

Some of it may also be availability at certain ED's. When I'm working in our main hospital, I can get any medication I want. If I'm at our much smaller free-standing satellite ED my choices are much more limited. I recently had a chronic migraineur who listed allergies to compazine, reglan and phenergan. I wanted to giver her either DHE, IV valproic acid or IV caffeine, but unfortunately we didn't stock any of them on-site. After speaking with her headache specialist our only choices were decadron, toradol, dilaudid and zofran; if I wanted anything else I'd be waiting several hours for a courier, or I'd have to transfer her to the larger ED.

[jmj11]

Do you have links to the protocols? I'd suspect a large part of it is a lack of familiarity with the protocols; we don't tend to get a lot of headache literature distributed to the ED's. I think many of us use therapies like reglan, compazine, toradol, etc because A) We are familiar with the drugs and their side effect profiles, and B) because they usually work. I've had excellent success for years with Compazine and/or Reglan with toradol (although the literature I've read supports Compazine over Reglan, so it's usually my first choice). Most of the folks I've worked with are hesitant to go right to ergotamines because of the concern for cardiovascular side effects and severe nausea/vomiting. The few times I've brought up DHE to refractory patients, several of them have told me that they couldn't tolerate the way it made them feel.

Some of it may also be availability at certain ED's. When I'm working in our main hospital, I can get any medication I want. If I'm at our much smaller free-standing satellite ED my choices are much more limited. I recently had a chronic migraineur who listed allergies to compazine, reglan and phenergan. I wanted to giver her either DHE, IV valproic acid or IV caffeine, but unfortunately we didn't stock any of them on-site. After speaking with her headache specialist our only choices were decadron, toradol, dilaudid and zofran; if I wanted anything else I'd be waiting several hours for a courier, or I'd have to transfer her to the larger ED.

 

Yeah, that makes sense (about not having the meds in-house etc.). That's what I meant by honest question. I'm busy right now but when I get the chance I will post some of the papers. If you have access to articles do a search for headache treatment in the ED or ER in the Headache journal. Nothing that anyone has posted has been unreasonable.

 

BTW, this is from an editorial in this month's Headache:

 

Most of an emergency physician's headache training comes on-the-job, ie, caring for the 2 million patients who present to EDs with headache. Emergency physicians are required by the Accreditation Council for Graduate Medical Education to be competent in headache care, but this is done with limited formal didactics. Most programs have no more than 2 hours of structured primary headache lectures per year. Therefore, the quality of an emergency medicine resident's headache education depends largely on the clinical teachers – attending emergency physicians and consulting neurologists and headache specialists. Is this sufficient? It is difficult to quantify the adequacy of headache care delivered in EDs by emergency physicians. On the one hand, there are many stories of substandard care. On the other hand, when surveyed, many headache patients seem satisfied with the care they received in the ED.

 

It is clear that ED care of headache can be streamlined and homogenized through the use of a thoughtful protocol.¹⁵ This would be developed by a team of interested and informed clinicians representing the relevant specialties. Protocols can be used to standardize workup of secondary headaches, determine criteria for admission to the hospital, homogenize parenteral treatment and discharge prescriptions, and expedite outpatient referral. Although substantial time would be required to develop a useful and flexible protocol appropriate for a specific medical center, it could result in improved relations between departments and a better experience for both the clinicians and the patients. Ideally, a protocol would decrease throughput time, determine the right balance of diagnostic testing, decrease medical error, decrease litigation, and improve pain outcomes for the millions of migraineurs who utilize US EDs every year.

[bradtPA]

http://www.benthamscience.com/cmccnsa/sample/cnsamc9-1/0008T.pdf

 

Good reading....

[EMEDPA]

we don't stock iv ergotamine or caffiene.

[sk732]

My first line is a litre N/S, Stemetil +/- Benadryl...or Maxeran. Second line is either IV or nasal DHE...the nasal DHE I find is pretty decent for refractory stuff. If they show up early enough and haven't done anything yet, there's alot to be said for trying 6-800mg of Advil liquid gels or 500mg of naproxen if their stomachs can handle it.

[xxbowiexx]

i noticed most of you guys did not include steroid in your treatment protocol. We recently had a discussion in our journal club about the efficacy of dexamethasone as adjunctive treatment in a migraine cocktail. Study shows a decrease in recurrent headache and subsequent decrease in return rate for acute migraine headache in the ED. Does these data correlates to your practice?

 

Here's the article supporting the use of steroid:

Does the Addition of Dexamethasone toStandard Therapy for Acute Migraine

Headache Decrease the Incidence of Recurrent

Headache for Patients Treated in the

Emergency Department? A Meta-analysis and

Systematic Review of the Literature

Amandeep Singh, MD, Harrison J. Alter, MS, MD, Brita Zaia, MD

 

 

At work we use Benadryl/Decadron/Reglan OR Compazine for our migraine cocktail

[dpc511]

NS bolus, toradol, reglan IV.

 

One of the docs likes Thorazine and Benadryl IM, but I haven't had great success with it.

[kismet]

There are several types of migraines (i.e. classic, with/without aura, familial hemiplegic, basilar-type) and so I’m curious to know how you folks chose your treatment plan with migraine in the ER as it appears to be quite similar. For example, if I had a patient (I’m no professional, just curious!) with BTM and cyclic vomiting with dehydration, I would probably focus my treatment with anti-emetics, IV fluids, pain control, however would not prescribe ergot derivatives or triptans.

On the other hand, with a classic migrainer, my treatment would be catered much differently depending on the complaints and the TYPE of migraine-- classic migraine: pain control with anti-emetics, possibly triptans). It would be much more patient-centered depending on type and complaints.

[jmj11]

I will just add, that most of what is shared is reasonable. Still, dihydroergotamine is the gold standard and should be used much more in the ED than is an we in headache don't understand that. I would demand that the ED carries the drug. You can still use the other treatments, neuroleptics, analgesics, steroids. I would also suggest if the headache is over 48 hours that you infuse 1 gram of valproate (unless contraindicated) as it has great success in status.

 

Besides not using DHE-45 in the ED, the second pet peeve is that these patients come back again in the ED but no one every refers them to us who manage these diseases. Once I get a patient under management it is rare they ever go back to the ED. I know it is not the responsibility of the ED to do referrals, but if someone came in with a fish hook in their eye, penetrating to the retina, you would refer them to Opth. Many of these repeaters either have no PCP or their PCP doesn't care enough to refer them.

 

Speaking of Basilar Migraine, it is a very rare condition. I have the second largest headache practice in the state and presently I have one Basilar Migraine patient. A couple of years ago I had two. In my thirty years of headache work I've had a handful of Hemiplegic migraine, none right now. Do I use DHE or triptans with these patients? No. Not because of any real risk, there are none. But because the FDA doesn't understand what these disorders are (thinking that they are vascular) and they've put in writing that these drug should not be used with these patients. So if you used one of these drugs and the patient had an infract (which is extreeeeeeeeeeemely rare) they would sue your ***. But there is no real risk of the drugs (DHE or triptans) causing an infarct.

 

My one BM patient presented to the ED just three weeks ago and they called me. They wanted to use IV sumatriptan and I said no for that very reason. I give them lomatrigine as an abortive.

[xxbowiexx]

you are right about referral to headache specialists for adequate management for repeaters. I will have to check for local headache specialists when i'm back at work.

[rcdavis]

Mike

 

I have been peeking in on this thread for a day in between patients, and have a couple quick thought.

 

First of which is, if these regimens that the guys have described above work, why doesn't the headache society consider them appropriate and incorporate them into the "standards"

 

In 40 years of doing this, I have YET to see a *neurologist, let along headache subspecialist, in my ED actually seeing or treating a status migraineur.. It's usually. ( if I can get them on the phone)" well, do what works to get them out of the Ed, and we 'll see them in the office"...( This from the same folks who promulgate the idea that status migrainous needs admission)

 

The idea that the ED be given a protocol for headaches probably won't flyand is terribly presumptuous....and I think based on a terribly flawed premise , that being that somehow the ED is doing the wrong thing by not giving DHE.

ED medicines approach to headcahes is is different than your, i think..

 

By the time the ED has gotten around to diagnosing *vascular headaches, we have already considered several layers of headaches, from the emergent, those that will kill you: epidurals and subarachnoids and sentinent *bleeds, meningitis, vertebral and neck artery dissection, etc...

To those which are less emergent, but still urgent: subdurals, space occupying lesions, abscesses, venous thromboses, vasculopathies, glsucoma, Pseudotumor cerebri, CO2 or CO or other toxin exposure

 

To those which are truly not life threatening, but painful or inconvenient: sinusitis, cervical radicular dental, stress, cafeine withdrawal, and the common and uncommon presentations of the vascular headaches.

 

ED residents get a whole lot more training than a two hour lecture on headaches..they consider headaches to be a life threatening event until proved otherwise.. And they have to consider every headache as a NON migraine until proven otherwise..they learn and consider as much *if not more of the subtitles of the headaches milieu than even internists... The same as we have to consider *chest pains on par with the cardiologists. We cannot be wrong. We jusually get one shot at the patient.. And rarely have the luxury of multiple visits. To do this well, we are much better trained than a simple lecture or two/

 

Once we do determine that the PT has migraines, there is little urgency for us except pain relief, and to help the patient regain some control over their headaches.

 

( and we have to do this while trying to ferret out the 800 pound gorilla of drug abuse from the truly distraught patient)

 

As I alluded above, we in the trenches, who see the majority of emergent headaches as a rather routine in our practice, have determined that the regiments of DECADRON, DEPACON, COMPAZINE, REGLAN, TORADOL, BENADRYL, O2( for cluster), caffeine ( for post lp)' DROPERIDOL ( even w/ the black box.. Works great), etc.. THEY ALL WORK,!!!

 

DHE works, but only during a certain phase of the migraines.

 

And it does not cover the " cross over headache" , that headache which is resultant to the pain of the migraine or the vomiting...and is nicely handled by the protocols above.

 

We trenches tend to use ' what works'

 

You specialists see nowhere the volume that we do... You see only the failures, and the misdiagnosed. You do not see the accurately diagnosed and adequately treated.

 

I appreciate that DHE is the standard for the classic, and most common migraines.. But there are a lot of side effects ( especially cardiac and cerebral vascular in a patient population not unlikely to have imbibed in a little, say we say, coca alkaloid), that make it a little risky.

 

Also, frankly, I have yet to find a true migraineur that does not respond to BENADRYL and REGLAN and decadron...( which also, btw, addresses the nausea wherein the dhe does not)

 

I think I will stay with what works for me.

 

Sorry about any attitude, but I hate it when a subspecialty decides that the front line ain't doing it right when they have no interest in being in that front line.

 

Getting appointments 6 weeks down the road does not help the patient in pain tonight .

 

So.. I put it to you.. Where is the harm that the ED is doing by not using DHE.. *And why no recognition of the benefit that we are doing.

 

ED were the ones which first reasized that Natricor CHF had some serious flaws .. and were the first to stop using it.. based on out EXPERIENCDE with it.. not just the data..

 

I think perhaps the headache society ought to consider incorporating a little more of what WE do ( after all...we were the ones that came up with the COMPAZINE or DROPERIDOL and benadryl approach ..not the headache specialists) than the other way around.

 

 

 

Rc

[xxbowiexx]

rc, your post is quite informative. I will continue using our migraine cocktail for the appropriate patient population, but to be fair i will also consider offer referral to headache specialists to our repeats.

[jmj11]

rc, I don't want to create a pissing match or a turf war. I certainly understand your frustration with your referral base. As I said, nothing that has been talked about by the ER providers here are unreasonable or "wrong" and keep using them if that's what you want to do. We each have our different perspectives.

 

However, I hear all day long how dissatisfied my patients were in their previous ER experiences and how many of the things mentioned above didn't work. Several studies have supported patient's dissatisfaction with the care they get in the ER. There have been several good studies of what does work and it isn't just based on what feels like it is working so my point is why do we have to reinvent the wheel but look at the data? I personally don't trust testimonials.

 

Regarding your statement: "Also, frankly, I have yet to find a true migraineur that does not respond to BENADRYL and REGLAN and decadron...( which also, btw, addresses the nausea wherein the dhe does not)" well, I could put you in contact with many patients who get the combinations and they did completely fail. There are NO 100% successful treatment for acute migraine. DHE has the highest marks at about 78-80% so it fails too. Yes, the patient dose need an anti-emetic with DHE. DHE is the only treatment proven to work anytime during a migraine, even months into a status migraine.

 

All of us who work in headache are on the front lines. All day long I'm working in acute headache patients and I'm working on setting up after-hours treatments at the local urgent care clinic where my patients can have standing orders. Most headache clinics provide acute care and often after hour acute care. At Mayo we set up 24 hour care in our out patient infusion center where we wrote orders in advance. We published a paper in 2002 (in the reference at the bottom) where the patients satisfaction, compared to the care which they had at the local ERs was almost double. So what we are advocating is for better care from our in-the-trenches decades of experience in treating headache patients in the acute setting not some ivory tower theory. Seeing emergent headache sufferers is what we do everyday too.

 

I will add that I've never admitted a patient for status migraine. It think hospitalization is a waste of resources and provides poor care for those patients. I leave them in their own beds in their own homes and have home health care nurse come out once a day for IV infusions . . . DHE, Reglan, Valproate, sometimes steroids . . . and many of the things you guys have mentioned.

 

I've worked ER in the past and it is tough. You have to know a lot of things about a huge spectrum of disease. I'm totally respectful of what you do but you can't know cutting edge about every medical disorder. BTW, we don't use the term vascular headaches anymore because they do not have a vascular etiology as we use to think.

 

Most of the ER providers I've talked to don't want to see headache patients because they have patients who they feel need their attention more. That is why one of my biggest goals with my patients it to create resources so they never have to visit an ER again but are successful in home treatment.

 

Below is another commentary, if you are interested, about migraine treatment in the ED. She is also summarizing a different article in the same issue but her summary was much more concise. I will mention too that Merle Diamond (reference number 5) is a board certified ER physician who worked ER for years before assuming the directorship of the Diamond Headache Clinic (from her father) in Chicago.

 

 

[h=1]Migraine in the Emergency Department: Not a Win-Win Situation[/h]

1. Lynn M. Rankin MD
   

Article first published online: 24 NOV 2003

DOI: 10.1046/j.1526-4610.2003.03203.x

 

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[h=2]Headache: The Journal of Head and Face Pain[/h]Volume 43, Issue 10, pages 1032–1033, November 2003

 

 

 

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Hypothetical scene from the popular US television show “ER”: Enter Dr. Carrie Weaver, no-nonsense attending. “Who has the migraine in 6? Why is she still here? Get her out of here! We have to make room for 4 teens with multiple GSWs.” And therein lies the crux of the problem: how to provide rescue care for migraine, an episodic condition which may be incapacitating but is rarely life-threatening.

 

The article by Blumenthal et al in this issue of Headache examines the emergency department (ED) experience for patients with primary headache as extracted from patient questionnaires correlated to ED records.¹ The authors draw attention to various issues inherent to the ED headache encounter, many of which have been reported by others in recent years.^2–6 These previous studies have been criticized due to methodologic concerns regarding ascertainment of subjects, incomplete documentation in ED records, lack of standardized diagnostic criteria, and lack of 24- or 48-hour follow-up data. While the percentage of responders to the questionnaire utilized by Blumenthal et al was low, this is typical of this type of study, and some familiar themes emerged. These include underdiagnosis of migraine as the specific primary headache type and underuse of “migraine-specific” medication.

 

Perhaps the striking result revealed by this study was the disconnect between the impression of the ED physician at the time of discharge and that of the patient 24 hours later. Although the ED notes indicated that a majority was improved at discharge, no patients were able to resume their routine activities immediately afterward, and 60% reported persisting headache at 24 hours. A perceived response to treatment as judged by the ED physician typically did not equate to a robust or sustained response in the patient's estimation. This article imprints in the medical literature what many of us have heard numerous times at office follow-up visits or at American Council for Headache Education (ACHE) support group meetings.

 

How can we improve rescue care for our patients? We can strive to improve the ED encounter, and we can try harder to keep our patients with migraine out of the ED in the first place. The latter can be accomplished by providing backup medication options for patients at home and by developing alternative settings for acute care. Reduced use of the ED was also demonstrated through a disease management model of care for migraine at Kaiser Permanente in which the focus was on education and individualized care plans.⁷

 

For various reasons, the ED always will see its fair share of acute migraine: spontaneous, unexpected, rapidly developing, acute headache in a migraineur grown complacent from a prolonged respite; depletion of home medications; overuse of abortive medication; attacks during travel; and lack of access to a primary physician, to name a few. The daunting task that falls to the ED staff is to obtain a thorough history and perform an adequate examination when the patient is often a stranger and always in misery. The ED physician is typically short on time, and the patient's ability to cooperate may be limited. Diagnostic specificity consequently may be compromised. In addition, if the physician fails to commit to migraine as the diagnosis, he or she may be less inclined to administer migraine-specific therapy. Utilizing a headache history check-off sheet in the ED might help. Such an instrument could incorporate the International Headache Society (IHS) criteria (presented simply and coherently), a list of red flags to help identify secondary headaches, screening questions for analgesic rebound headache, and a list of non-opioid therapeutic options that included those less familiar to many ED physicians (eg, sumatriptan SQ, droperidol IM, chlorpromazine IV, dihydroergotamine IV or IM, divalproex sodium IV). Since headache is the presenting complaint in 2% of all ED visits,^2,8 and given that headache requires a detailed history for proper diagnosis, utilizing a simple headache history intake form could improve documentation, diagnosis, and clinical outcome.

 

Maizels has described the headache “repeater” and found that in his large health maintenance organization, 10% of the patients who visited the ED for primary headaches accounted for 50% of the total visits.⁸ With this population in mind, a few years ago I developed a home-based migraine treatment program involving administration of rescue medication per standing orders and a visiting nurse. This pilot project was part of a migraine treatment initiative supported by the local Blue Cross/Blue Shield carrier. Unfortunately, although patient satisfaction was high, the cost of such care was prohibitive. The program consequently had to be abandoned, but the intent led to increased use of an infusion center and expanded hours for that center; this center was better equipped to meet the acute needs of known migraineurs than was the ED or our private office. In a Mayo Clinic study evaluating patient satisfaction with this infusion center model of care, 3 groups of patients with migraine were surveyed: those who had visited the hospital ED, those who had visited a walk-in urgent care center, and those who had visited a dedicated infusion center. Wait times and cost of care were lowest for the infusion center, while patient satisfaction was highest.⁹ Thus, an infusion center with expanded hours might fit nicely into an overall management plan for “repeaters,” especially provided that other confounding issues such as abortive drug overuse are addressed. Protocols for the optimal infusion center should include a stated limitation on frequency of use, and parameters for frequency of use should be reviewed at regular intervals.

 

Health care delivery in the United States increasingly is channeled into “systems” that favor treatment pathways over ad hoc and often haphazard care. We have the opportunity to work with our colleagues within these systems to achieve better care for the migraineurs who inevitably will present in need of acute medical attention.

 

 

Jump to…Top of pageREFERENCES[h=3]REFERENCES[/h]

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  Blumenthal HJ, Weisz MA, Kelly KM, Mayer RL, Blonsky J. Treatment of primary headache in the emergency department. Headache.NovemberDecember 2003;43: 1030-1035.
  

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  Fiesseler F, Kec R, Mandell M, et al. Do ED patients with migraine headaches meet internationally accepted criteria Am J Emerg Med.2002;20: 618-623.
  

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  Ducharme J, Beveridge R, Lee J, Beaulieu S. Emergency management of migraine: is the headache really over Acad Emerg Med.1998;5: 899-905.

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[pawag]

IV NS bolus + Compazine 5mg + Benadryl 25mg (+/- Toradol 30mg IV)

 

The NS + Compazine + Benadryl seems to work every time even with the not yet Dx SAH pt. Interestingly this pt's CT was negative to the radiologist (questionable to me) and she absolutely refused LP initially. Eventually I was able to talk her into it and there it was orange/yellow CSF. Pt did great.

[RetNavyPAC]

Compazine/Reglan + Benadryl + Decadron (if headache >24 hours). Knock 'em down, let 'em sleep and when you wake them up 45 min later they almost always feel much better - if the headache isn't actually completely aborted. This combo, in my experience, works about 90-95% of the time

 

If that doesn't work I'll try to use Droperidol - which I don't think anyone has mentioned yet. I say 'try' because a few of the younger attendings in my dept trained in programs where it wasn't used ('banned' by the hospital or health system for the B.S. QT prolongation concerns). But all the older EM guys/gals do love the stuff. I've had as little as 0.625mg IV work like magic fairy dust for a recalcitrant migraine.