Migrane Headache Treatment in the ED

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    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.

    Again it's patient dependant......

    CEN35
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    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.
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    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?
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    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?
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    Our ED has had great success with a liter NS bolus with benadryl 50mg per liter, this is usually enough to eliminate the need for demerol, in some cases we also add toradol 30mg ivp, then D/C to home.
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    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
  10. 0
    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.
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    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
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    We had a EP that introduced us to what we called the "Migraine Cocktail".
    O2 at 2lmp via nc
    Toradol 30 IV
    Compazine 10 IVP (some added to 250cc NS)
    Decadron 4mg IV

    90% were relieved of the pain....
    Now we have a new group of EP and some will give the Narcotics injection or IV and NO RX for pain.



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