Migraine treatment in er

[dsherman]

I am wondering what your er does as far as migraine treatment. We use reglan 10 mg IVP benadryl 12.5 mg IVP dexamethasone 4 mg IVP or Solu medrol 125, morphine 6 mg IVP or Dilaudid 2 mg IVp

[edmia, BSN, RN]

Truly depends on the provider but slowly moving away from narcotics.

IVF bolus, zofran, and toradol. Often with the addition of Ativan. Low lights and hope it breaks quick. Migraines are so debilitating. I really feel for these patients.

[1fastRN]

Why do narcotics cause rebound pain? Vasodilation?

Just curious on the pathophysiology...

[Anna Flaxis, BSN, RN]

twss2323,

Toradol for the pain, Compazine for the N/V, and Benadryl for the potential akathisia caused by the Compazine.

[dsherman]

i am unsure why narcotics cause rebound pain but my hospital gives decadron or Solu-Medrol and have ever heard any report of rebound when the steroids are given with the narcs

[CodeteamB]

From what I understand, rebound headaches can be caused by any analgesic including Tylenol and Ibuprofen, it is more about the way they are used.

So, you have a headache and take 1g Tylenol and 600 ibuprofen. 3 hours later you start to feel the twinges coming back and take another dose to prevent the headache. You continue this for a couple of days, now every time your meds wear off you have a low level headache. Apply this to narcotics, triptans etc.

Perhaps this is worse with narcotics than other medications. I actually have never heard rebound headaches as a rationale against narcotics for migraine, just that research indicates that they are not necessary/as useful as the meds we do use.

I know my strategy with my own god-awful migraines is 400 ibuprofen, 1g of Tylenol, dark, silent space and an ice pack over the affected eye, then I lie there 'tilI I fall asleep. Luckily I have never woken with a headache

[zmansc, ASN, RN]

A good read on opioids and rebound headaches is Migraine, narcotics, & rebound headaches

Basically, the blocking of the receptors causes the release of more transmitters, so when the opioid wears off, you end up having a stronger signal to block, thus a high likelihood of a followup headache that may be even worse.

[Anna Flaxis, BSN, RN]

^ That's my understanding, too. Not that narcotics cause rebound headaches, but that evidence shows that they just don't work as well as other meds (I wrote this in response to CodeteamB's post, before the post directly above. I will check out the link. Thanks.).

I was curious about the steroid, since I've not seen that in my experience, so I did a little research and read that a significant percentage of patients discharged from the ED have recurrence of headache post discharge, but that with the steroid, this is significantly reduced. I'll be sure to mention this to the docs where I work.

My migraines have significantly decreased since I switched to a progestin only BC med, but when I get them now, which is rare, I usually take some ibu, drink a full glass of water, and lie down in a dark room. Only once have I ever sought medical attention, when the headache had been going on for 3 days and nothing I did at home was working. I went to Urgent Care and requested an emergent head amputation, but instead they gave me the Toradol/Compazine/Benadryl cocktail IM, and that did the trick quite well.

[exit96]

Benadryl, Phenergan, Toradol, Maybe Decadron...depends on the provider. But most of the Providers I wiork with try very Hard to avoid Narcs...they are not indicated for Migraines.

[NeoPediRN]

Imitrex injection, toradol, Benadryl, and Reglan.