I'm doing a reasearch project and am looking ofr information on how other hospitals are treting Migrane patients. What drugs are you using and why? Do you have any written protocols or a no narcotics policy. any help would be appreciated
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In our ER it depends on the patient and allergies. One of the most common things used, is an IV fluid bolus of NSS (which is usally 1 liter if there is no history of CHF and/or they can tolerate the fluid).
In addition, for those without history of migraines, we give them Compazine 10mg IVPU with the fluid. Sometimes rarely, Reglan 10mg IVPU is used also. If that fails to work after 15 - 20 minutes, and there is a delay in CT they may also get Demeral 25mg/Phenergan 12.5mg IVPU also. (The thought's behind these, are not to use an NSAID until a bleed is ruled out). Then they get a CT of the head to r/o bleed, mass or or abnormality that could cause the H/A.
If there is no apparent disease, bleed or CHI, they may get Toradol 30mg IVPU also.
If at that point they cannot get the pain controlled (rarely) they get admitted with a neuro follow up.
If they have been in before, and follow up with a neurologist......we will go right Toradol, with Demerol/Phenergan.
Basically when it comes right down to it, it becomes patient dependent. Some patients claim to be allergic to NSIADS, Tylenol and/or compazine. Some have had extra pyramidal effects from Compazine. do they have a history of migraines? What usually works for them and what doesnt? we have used imitrex, midrin and DHT in the ER.
Depending on MD and Pt our common treatment is a bolus of ns-1000cc and Maxeran or Stematil 10mg IV. After that each MD goes their own way be it narcotics, NSAIDS (Toradal), Decadron or a combination of the above. Different than above, for the most part we do not do CT's unless there is a focal or general defecit noted.
migraines, and the ed what a headache. I do believe that there are some real cases but there are also some flyers too. in most situations it just depends on the doc but it never fails that we have a bad trauma and some acute mi's and the pt with the migraine is demanding his drugs and during this time the dr will order a shot and the pt d/c. about 50% or more of these pt's are medicare and it just really makes you wonder sometimes. They never follow up and use the ed as there primary trt. in some cases it is almost a legal addiction and the md's just keep feeding them what they want. like i said there are some true cases but when a pt is allergic to everything but demerol and come in requesting it you have to wonder. we pull out "the book" and they have been in 47 times in the last nine months it really makes you wonder you inform the md but the chart is already in the rack for more narcotics to be given. does this happen anywhere else?
I suffer from occasional migraines, which are relieved by imitrex. I have been surprised that in the two times I have been to the ED (in 10 years), the MD's offer narcotics first. Being allergic to most narc's- I only want my imitrex. Where I work, the MD's tell me that Demerol is cheaper than Imitrex. Is this why? Or is it just the amt of frequent flyers who are "allergic" to imitrex?
Our ER uses Benadryl and Compazine to treat migraines, usually (not always) works like a charm.
Originally posted by keaston: I'm doing a reasearch project and am looking ofr information on how other hospitals are treting Migrane patients. What drugs are you using and why? Do you have any written protocols or a no narcotics policy. any help would be appreciated
Originally posted by hollykate: I suffer from occasional migraines, which are relieved by imitrex. I have been surprised that in the two times I have been to the ED (in 10 years), the MD's offer narcotics first. Being allergic to most narc's- I only want my imitrex. Where I work, the MD's tell me that Demerol is cheaper than Imitrex. Is this why? Or is it just the amt of frequent flyers who are "allergic" to imitrex?
Hollykate: I believe the doctors' reluctance to use Imitrex is because it has significant cardiac ramifications. Also, it's much more effective if given at the onset of aura rather than when HA is full blown.
to the majority of our patients we give an IV bolus 500 - 1000cc and maxeran 10mg IVP. Wait 20 minutes and then give DHE .5mg IVP can rereat DHE in 20 minutes PRN. It works really well for most headaches.These meds can also be given IM but seems cruel to give so many IM's
We base treatment on presentation of the problem. No n/v accompaning HA? MDs give a dose of Demerol 50, Phenergan 25 and send them on their way. These of course are our flyers more times than not. We treat and street. On the other hand, Our "true" migraines (you know the ones.. come through the door puking on you, beg you to turn the lights off) get a detailed Hx, if they have never had a migraine MDs order a CT and treat with L of NS and start with Toradol. If no relief follows we advance to Demerol. I think MDs are very quick to administer narcs, and should be more cautious with whom they give them to. I guess with a full ER and 40 in the lobby its easier to write orders for an injection and a note saying "see you next week".
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If they aren't frequent flyers, and truly have a migraine, they may get narcs from some of the docs. Some docs tell the FF's that "sorry, you've been here too often, call your doctor, you won't be getting anything from us".
Others give NSS bolus plus compazine and benedryl or inapsine.
Sometimes as a nurse I have a problem not treating patient's pain. I was taught "the patient's perception of pain is the truth, no matter what the doctor or nurse thinks". But the ER seems to make us callus. It's awful I think.
Much like previous writers, we use a combination of Reglan, Compazine, Toradol and Narcotics. We periodically use imitrex but that is rare, for whatever reason.
There is a treatment that one of our contingent Physicians uses...He works at a major teaching center near me and they have been doing a study on it...They use intranasal lidocaine....He instills between 1-2cc of 1% plain lido...The results are dramatic...There was a lady in the other day with an incapacitating headache (not the usual ER migraines that are reading a magazine when you go the waiting room)...he instilled the lido and in less than 30 minutes, she was pain-free. None of the other docs. have started using this tx, and I doubt that it is commonplace anywhere. I was suprised to hear about it...I will be anxious to hear about any other replies...