What's your favorite migraine treatment in the ER?

[jmj11]

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.

 

Droperidol is a great treatment as far as efficacy goes. I think someone mentioned it. I haven't used it . . . although I've consider it before. I've hesitated because the person who first turned me on to it Todd Rozen eventually stopped using it due to side effects. I do say that no treatment breaks the 80% efficacy mark and if any one treatment was 90% it would be the most profound development in headache treatment in a decade. I'm just trying to keep people honest. Migraine is notorious for failing even the best treatments.

 

I heard an Urgent Care PA claim 100% success in acute migraine treatment by using beads and pressure points on the ears, my wife just heard a NP speak and she said she and 100% success rate in curing all migraine patients because all of them had PFO and when closed their headaches went away. Both of them were bogus.

 

I agree with you that Droperidol has one of the highest success rates, up with DHE, and certain is a good option if the patient can be monitored.

[rcdavis]

God almight mike, what a thoughtful and complete response. It will take me a little bit to read through the references.

 

Of course a dedicated headache center would be of benefit .. To the patient and the ED, the same as a dedicated chest pain center, or dedicated abdominal pain center, etc.

 

But that doesn't seem plausible today. And, even if it were, experience again shows that the ED Would become the first line screener ( as we are now for chest pain centers).

 

Of course I would rather abort than treat. SQ sumatriptan, dhe etc do work ( btw, I have met my first sumatriptan addict I think.. Who goes Ed to Ed getting scripts and taking up to 12 injections a day.. Even when she isn't having headaches), but the subset of true migraine patients is small enough ( and NO WHERE NEAR 2%) that sometimes I admit to choosing broader, more shotgun approaches.

 

There is a big disconnect between observational and retrospective analyses and the real world. While I tend to be thoughtful and am not at all adverse to practice review and discerning flaws throw met analyses, a subspecialty organization determining that the majority of Ed patients were not happy about there Ed visit 24 hours after that visit evaluating the problem the subspecialty covers is hardly... Surprising.

 

NO ONE THINKS THE ED DOES AS WELL AS THEY DO, for anything.

 

But wait.. Think about this. What a quantum shift there has been.. From the ED response to any presumed vascular ( sorry old habit.. "Gay" is easier than "men who have sex with men") headache being DEMEROL and PHENERGAN IM and OTD, to our current practices of considering alternative (and more time consuming) therapies involving virtually no narcotics unless there has been incomplete resolution of symptoms...

 

I realize that you are seeing loads of misdiagnosed and maltreated patients. I guess it is that we are seek different sides of the elephant.

 

I would not mind , in fact I would applaud, a QUICK SCREENING questionnaire. I would not hesitate to try it ( I also suspect that I do it already).

 

And I appreciate that your emphasis is more patient centered than maybe mine is.. My patient centered concerns are colored by an urgency of simple survival.

 

I am - at least in the southeast- now the defacto primary care provider and safety net for a majority of my local population.

 

And the competing concerns of doing the best we can for the greatest number, increasing patient satisfaction, decreasing turn around times, while refusing chronic care to those folks who cannot pay a $250 up front copay( a whole different story and problem administration wants me to do to decrease the millions of dollars they lose a year in ecess of what they are reimbursed by The government for), have put me in a mode of simply surviving when I go to work. I can see another 2.5-4 patients in the time the migraineur occupies their bed while getting their treatment.

 

So which do I do? Me? I see one at a time and do the best I can in the time I think appropriate. If they tell me, after treatment, that they are feeling better, then that is all I need to hear to discharge them. I may not make them headache free... Headache " better"is okay.

 

So, let me review your articles, maybe there is something we can all learn from this dialog, even as this old dog snarls at you metaphoric new kids creeping into his yard and commenting on the status of his droppings...

 

My frustration , mike, is that I would LOVE to be able to provide state of the art care. For everyone. But real world circumstances would seem to collude against that from happening.

 

So I do the best I can.

 

We want the same thing mike. I just don't have the money or the time or the circumstance to make it happen.

 

Anytime the IHS wants to come to the Carolinas and open a clinic which will see headache patients 24hours a day, no money upfront, with a 36% collection rate, is a day I will personally deliver to you a three course meal and a motorcycle so you can get to your clinic in even more studly fashion than you already do. :)

 

I would request that all us ED guys review mike's references and compare them with the Ed literature.

 

Sorta a journal club thing.

 

Patient, complaint, and medically centered.

 

Sorta like we used to do on this forum all the time.

 

I am interested in hearing from you all .. I will be reading and researching for the next day or two.

 

Mike, are we still friends?

 

Rc

[jmj11]

God almight mike, what a thoughtful and complete response. It will take me a little bit to read through the references.

 

Of course a dedicated headache center would be of benefit .. To the patient and the ED, the same as a dedicated chest pain center, or dedicated abdominal pain center, etc.

 

But that doesn't seem plausible today. And, even if it were, experience again shows that the ED Would become the first line screener ( as we are now for chest pain centers).

 

Of course I would rather abort than treat. SQ sumatriptan, dhe etc do work ( btw, I have met my first sumatriptan addict I think.. Who goes Ed to Ed getting scripts and taking up to 12 injections a day.. Even when she isn't having headaches), but the subset of true migraine patients is small enough ( and NO WHERE NEAR 2%) that sometimes I admit to choosing broader, more shotgun approaches.

 

There is a big disconnect between observational and retrospective analyses and the real world. While I tend to be thoughtful and am not at all adverse to practice review and discerning flaws throw met analyses, a subspecialty organization determining that the majority of Ed patients were not happy about there Ed visit 24 hours after that visit evaluating the problem the subspecialty covers is hardly... Surprising.

 

NO ONE THINKS THE ED DOES AS WELL AS THEY DO, for anything.

 

But wait.. Think about this. What a quantum shift there has been.. From the ED response to any presumed vascular ( sorry old habit.. "Gay" is easier than "men who have sex with men") headache being DEMEROL and PHENERGAN IM and OTD, to our current practices of considering alternative (and more time consuming) therapies involving virtually no narcotics unless there has been incomplete resolution of symptoms...

 

I realize that you are seeing loads of misdiagnosed and maltreated patients. I guess it is that we are seek different sides of the elephant.

 

I would not mind , in fact I would applaud, a QUICK SCREENING questionnaire. I would not hesitate to try it ( I also suspect that I do it already).

 

And I appreciate that your emphasis is more patient centered than maybe mine is.. My patient centered concerns are colored by an urgency of simple survival.

 

I am - at least in the southeast- now the defacto primary care provider and safety net for a majority of my local population.

 

And the competing concerns of doing the best we can for the greatest number, increasing patient satisfaction, decreasing turn around times, while refusing chronic care to those folks who cannot pay a $250 up front copay( a whole different story and problem administration wants me to do to decrease the millions of dollars they lose a year in ecess of what they are reimbursed by The government for), have put me in a mode of simply surviving when I go to work. I can see another 2.5-4 patients in the time the migraineur occupies their bed while getting their treatment.

 

So which do I do? Me? I see one at a time and do the best I can in the time I think appropriate. If they tell me, after treatment, that they are feeling better, then that is all I need to hear to discharge them. I may not make them headache free... Headache " better"is okay.

 

So, let me review your articles, maybe there is something we can all learn from this dialog, even as this old dog snarls at you metaphoric new kids creeping into his yard and commenting on the status of his droppings...

 

My frustration , mike, is that I would LOVE to be able to provide state of the art care. For everyone. But real world circumstances would seem to collude against that from happening.

 

So I do the best I can.

 

We want the same thing mike. I just don't have the money or the time or the circumstance to make it happen.

 

Anytime the IHS wants to come to the Carolinas and open a clinic which will see headache patients 24hours a day, no money upfront, with a 36% collection rate, is a day I will personally deliver to you a three course meal and a motorcycle so you can get to your clinic in even more studly fashion than you already do. :)

 

I would request that all us ED guys review mike's references and compare them with the Ed literature.

 

Sorta a journal club thing.

 

Patient, complaint, and medically centered.

 

Sorta like we used to do on this forum all the time.

 

I am interested in hearing from you all .. I will be reading and researching for the next day or two.

 

Mike, are we still friends?

 

Rc

 

Of course we are still friends. I respect tremendously what you folks (ER) do. If medical knowledge had mass, I'm sure your brain would outweigh mine on any day. Like I've said all along, every idea mentioned here by ER types are appropriate for headache treatment.

 

Each of us lives in the world that we are given ( that didn't come from Donald Rumsfeld did it?). In your world you are up to your eyeballs and you have no other resources. In my world, our streets are crawling with headache sufferers who visit the ER over and over, and who are admitted to the hospital and doped up, but never have a referral. I know because my wife works in the ER and on the floor. Occasionally these patients do make it to my office, through direct advertising. They are a mess. However, I spend 90 minutes with them on the first visit and 30 minutes on the follow ups. I have the time and means to help them. I don't blame the ER as much as their PCPs. I have several groups that send me patients daily. There's two large practices on the island who (groups of 5 providers each) have never-ever sent me a single patient. When I do see their patients, they are a mess. They have never had good care. So, as you are speaking from your experience, I speak from mine. Of course we are still friends.

[paprospect24]

jmj I apologize if this is a stupid question and I don't mean to hijack the thread but why is dihydroergotamine the gold standard if studies have not consistently shown a significant correlation between dilatation of cerebral blood vessels and pain or other symptoms of migraine or cluster headaches, or between the vasoconstrictive effect of an ergot derivative and relief of these headaches?

[jmj11]

jmj I apologize if this is a stupid question and I don't mean to hijack the thread but why is dihydroergotamine the gold standard if studies have not consistently shown a significant correlation between dilatation of cerebral blood vessels and pain or other symptoms of migraine or cluster headaches, or between the vasoconstrictive effect of an ergot derivative and relief of these headaches?

 

We are now confident that vasodilation has nothing to do with the syndrome's (migraine nor cluster headache ) cause or pain, it is an after-effect in the same way that edema is to an inverted ankle strain. The way that DHE works is not via its vasoconstricting mechanism by by its 5 HT 1 B and D agonist qualities in both the brain-stem (periaqueductal grey) and at the peripheral nerve endings of the trigeminal nerve. By increasing 5 HT 1 B and D "tone" you reverse the cascading events that lead to the release of the inflammatory neuropeptides (substance P, VIP, neurokinin A etc.), which in turn active the pain on the trigeminal nerve sensory endings. The next generation of migraine and cluster treatments (due to hit the market by the end of this year or early next year) have NO vaso-constricting properties. These products have already been studied in patients with unstable CAD and their is no cardiac side effects.

[paprospect24]

If there was a "thank you" button on this forum I would hit it. Thank you for the detailed response.

[jmj11]

If there was a "thank you" button on this forum I would hit it. Thank you for the detailed response.

Just don't use what I said on a cert exam or in PA school or you will be graded wrong. I taught in a PA program (just one lecture per semester) and the textbook and hand outs still used the same headache notions as we had in the early 1980s. I will use your "thank you" pints to try and neutralize my coming across like an *** previously.

[paprospect24]

Just don't use what I said on a cert exam or in PA school or you will be graded wrong. I taught in a PA program (just one lecture per semester) and the textbook and hand outs still used the same headache notions as we had in the early 1980s. I will use your "thank you" pints to try and neutralize my coming across like an *** previously.

 

Something that has always frustrated me, in almost every science class there is the correct answer supported by current research and then there is the outdated answer that the instructor wants you to learn for the test. Or there are always the exceptions that the instructor is not aware of. I feel like I am learning twice the information sometimes and its often confusing.

[dpc511]

DHE is the gold standard. This is true. One problem with it's use in the ED though, is that it is a pregnancy category X drug. That means we would have to have a negative urine pregnancy test on every female with a migraine before we could give it. By the time a urine sample is obtained from the patient and resulted by the lab, the migraine could have already been well controlled by one of the other regimens. It is otherwise a great drug.

[jmj11]

DHE is the gold standard. This is true. One problem with it's use in the ED though, is that it is a pregnancy category X drug. That means we would have to have a negative urine pregnancy test on every female with a migraine before we could give it. By the time a urine sample is obtained from the patient and resulted by the lab, the migraine could have already been well controlled by one of the other regimens. It is otherwise a great drug.

 

Regarding DHE-45 I give it routinely in my office and have so for 30 years. I don't give any drugs to pregnant women and certainly not DHE. But that issues just doesn't come up. I think of the people I've given to in the last few weeks and it had been 3 men, 1 male child, 4 post-menopausal women, 2 post-hyst women. I do give it to fertile women but with the statement that this cannot be used in pregnancy, are there any chance you could be? If they no, I document that. I know the ER has different standards an may require a pregnancy test for each fertile female, but then I would apply to any non-A cat drug given in the ER.

 

I will broaden this to my main point. What is the goal in treating migraine in the ER? If the goal is simply to get the patient feeling better for awhile, so you can get them the hell out of your ER, then shoot them up with Demerol the moment they walk in the door. Then they go home and when the numbing wears off the headache is still there. After all, pain is only one part of the migraine syndrome.

 

But, I think our objective is to treat the disease state. For too long migraine has relegated to a position of "psychosomatic" disease. Virtually all my patients have had their lives ruined by migraine (before seeing me, and not after, I hope) and I've had two suicides this year. That is an average. It is a real biological disease that needs to have the same respect as and MI, acute RAD attack and etc.

 

So, if an MI comes in the door is the goal to give them enough MS to take away the pain so you can discharge them? I realize that MS does have some cardiac therapeutic benefits but it wouldn't be the stand alone treatment for an MI. The same for an acute asthma attack. You could probably load them up on enough diazepam than they loose their suffocating panic, but their pulse ox won't improve.

 

So, migraine is a real biological disease. We focus on treating the disease. Now I'm not poo-pooing using narcotics, they have their place. They have their place for two reasons, compassion and they can have an indirect disease modifying effect by numbing up a person's head long enough and sedating them enough that they can go home and sleep for 4 hours. Sleep is a migraine reversing treatment.

 

But acute disease reversing medications that we know of are dihydroergotamine, triptan class, anticonvuslants, steroids and neuroleptics. Soon we will have another new class of disease modifying treatments in the cacitonin gene related peptide antogonist (CGRP) coming to the market.

 

So that is my only point are we treating the disease or are we treating the ER staff by getting the out of our hair (I say "our" because I have worked the ER in the past)? I will add that for the repeaters, those who are in the ER for migraine multiply times in the month, the ER treatment may be making their disease worse. I do realize like was mentioned before that many towns have no other resources such as a headache clinic or a neurologist who takes headache seriously . . . or gives a damn. Just a thought.

[dpc511]

Point taken. I think you mentioned earlier too, that there needs to be more referral from primary care to headache specialists. We do have those resources in my area. Problem is, most of the folks that come in several times per month with what seems to be true migraines don't have a PCP, never follow up with their PCP as directed, or have a PCP that doesn't care enough to refer them to a specialist (maybe because the PCP has never actually seen the patient during a migraine). I try to spend a fair amount of time educating these patients on the need for follow up and further workup as an outpatient, but for most it falls on deaf ears.

[chris263]

Regarding DHE-45 I give it routinely in my office and have so for 30 years.

 

JMJ, could you please share your protocol? Thx.

[fireguy]

NS, compazine, norflex, Decadron, +/- toradol. and DHE if no HTN hx. Sometimes add benadryl or sub q triptan. Occasionally caffeine

[chris263]

NS, compazine, norflex, Decadron, +/- toradol. and DHE if no HTN hx. Sometimes add benadryl or sub q triptan. Occasionally caffeine

 

Benjamin, how are you administering the DHE? Are you following Raskin protocol?

[janede]

re reglan idiosyncratic, akathisia effect :thats why you give the benadryl first, the reglan should be given in a pump over 10 minutes, less that 20m

my recipe

I give 1 L NS, 10 reglan, 25 benadryl, if neg/preg, toradol...I have no issue if the pt is not a huge ER utilizer of adding a narc if they request: I tell their beside person (and the staff) to try to help pt sleep as that seems to be a real trigger to resolution, ..Im totally aware of narc rebound and abuse issues...I FAX these pts chart to the primary or local HA clinic or pain clinic, so they are aware of the ER visits and I tell the pt that, I do not give narcs scripts for home: usually Maxalt or Nsaids

[janede]

re reglan idiosyncratic, akathisia effect :thats why you give the benadryl first, the reglan should be given in a pump over 10 minutes, less that 20m

my recipe

I give 1 L NS, 10 reglan, 25 benadryl, if neg/preg, toradol...I have no issue if the pt is not a huge ER utilizer of adding a narc if they request: I tell their beside person (and the staff) to try to help pt sleep as that seems to be a real trigger to resolution, ..Im totally aware of narc rebound and abuse issues...I FAX these pts chart to the primary or local HA clinic or pain clinic, so they are aware of the ER visits and I tell the pt that, I do not give narcs scripts for home: usually Maxalt or Nsaids

[Emerson]

Reglan, Toradol, Decadron is my cocktail of choice. Recently had success with IV Acetaminophen which we just received in formulary.

[jmj11]

I had a patient ask me this week to set her up to do self-administered IV Droperidol in her home PRN. Hmm, I knew of a cardiologist from Las Vegas who would be willing to do that for $$$ . . . but not me.

[CAdamsPAC]

Of course we are still friends. I respect tremendously what you folks (ER) do. If medical knowledge had mass, I'm sure your brain would outweigh mine on any day. Like I've said all along, every idea mentioned here by ER types are appropriate for headache treatment.

 

Each of us lives in the world that we are given ( that didn't come from Donald Rumsfeld did it?). In your world you are up to your eyeballs and you have no other resources. In my world, our streets are crawling with headache sufferers who visit the ER over and over, and who are admitted to the hospital and doped up, but never have a referral. I know because my wife works in the ER and on the floor. Occasionally these patients do make it to my office, through direct advertising. They are a mess. However, I spend 90 minutes with them on the first visit and 30 minutes on the follow ups. I have the time and means to help them. I don't blame the ER as much as their PCPs. I have several groups that send me patients daily. There's two large practices on the island who (groups of 5 providers each) have never-ever sent me a single patient. When I do see their patients, they are a mess. They have never had good care. So, as you are speaking from your experience, I speak from mine. Of course we are still friends.

 

I thank both of you gentelmen and the others who have posted "their secret H/A formulas" in this thread . I've used DHE on occassion and have had some good and not so good responses. I do like response and use the Toradol, NS, Phenergan cocktail in my current U/C job but I will be trying some of the listed Rx. Thanks again.

[jns9990]

So for those of us who are allergic to reglan and toradol they can be substituted with nubain and vistaril? I was diagnosed with daily chronic migraines and my pain management Dr doesn't exactly know what to do anymore. The ED is cracking down on narc usage to only 4mg which by the time I get there is never enough. So could a treatment for me when things get bad be nubain 10, vistaril 25, zofran 4, and benadryl 25?

I've also read on here about decadron. Think you could explain that one to me? Actually there is a lot I've read on here that I would like to know more about.

[chiefPA]

2mg Haldol, 1mg Ativan , toradol

[skyblu]

IV fluids, O2 via NC, IV reglan and toradol (if neg UCG and no bleeding suspicion), but I prefer to avoid narcs because they can cause rebound HA.

[jmj11]

Narcotics can cause rebound (or what we now call Medication Overuse Headache Syndrome), only if taken > 3 days a week for extended periods of time. They have their place in humane headache treatment if other things have failed and they are not given in the context of MOH, just as narcotics have a place in fractures, blunt trauma and etc. It is standard of care to allow an injectable narcotic up to three times per month in that patient who is not in MOH, who is not in substance abuse (taking daily or near daily opioids) who has failed their abortive treatments and who is doing other measures (followed by a headache manager and is working hard on preventative measures).

[jwells78]

You know my favorite? The "I can't- give you narcotics because you've been here 6 times in the past month for the same thing and you're drug seeking with a positive meth utox and we'll likely have to have you escorted off the premises- AGAIN" treatment! Works every time!

[winterallsummer]

Very interested in this as I saw a ton of migraines in the ER during a rotation.  Seemed that pts fit into two categories - either were

 

1. Fixed up within 30 mins with the standard Phenegran OR Reglan, +/- Toradol, +/- fluid, +/- benadryl

2. Had no relief with that treatment (or naseau resolved, HA persisted) and didn't even get much relief with addition of narcs and basically left with a HA and referral to neuro.

 

I did not see DHE or triptans used once.  I did ask and basically PAs or docs were not using these because they were not familiar with them (that is, used them 1-2 times total in the career) and were scared of the ADRs of DHE.  I do know in our pharm class we were basically taught that DHE is a very nasty drug that should be avoided by non-specialists.   On another note I did see a pt with previously dx'd tension HA get complete relief with O2 only.