what treatment do patients who present with migraines......

Specialties Emergency

Published

to your ER recieve????

were i used to work it was just the usual peth and maxalon im injection. but this stopped about 3 years ago and now they only give chlorpromazine infusion. since doing this the number of migraine presentations dropped by about 80%

now in the place i work which is out in the country the Dr seems to only give peth. ive given him the literature on this and that we shouldnt be giving narcotics but he still does. so what im wanting to know is what have you guys found most effective?

Unfortunately, in our ED the "fix" for migraines is dilaudid and either phenergan or zofran. As you can imagine, we have daily "visitors" that are having "the worse migraine ever". We've spoken to the docs on this and the bottom line is that most can't be bothered with a confrontation if narcs aren't give. I've thought of refusing to give the narcs when we know we're dealing with a drug seeker.

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Specializes in Level III cardiac/telemetry.

I've had to go to the ER twice with migraines, and it is a last resort - puking my guts up for hours and ready to shoot myself. Had been trying the regular rxs - imitrex, zomig, topomax daily, and so on. Frist ER visit they gave me reglan, benedryl and compazine - wonderful! Narcotics do NOT work - I have them in my closet because of other chronic pain issues and they simply do not work on migraines. I could OD on demerol, lortab, etc and still have a killer migraine. The second time I went the waiting room was packed and the registration clerk told me it would be a minimum of 8 hours before I was even seen. (I was interning there in phlebotomy and talked to a patient the next day who had waited in the lobby 10 hours before finally making it back to a bed and then finding out he had meningitis) I said "well, in 8 hours hopefully my headache will either have been gone or I will have killed myself." They asked if that was a threat, so I asked if it would get me back any sooner and they just smiled and said no so I left.

I've since found out I have a pineal gland cyst which is not supposed to be symptomatic but they do MRI's every 6 months JIC. I also now take Relpax which is a drug sent from Heaven! I don't have any side-effects from it and it works in under 25 minutes.

As for the benedryl/compazine (not really asking for medical advice here, just curious) is there something about it being given by IV that makes it effective, or do you think taking it po would be as effective. I once had a dr give me compazine suppositories for when the nausea was so bad with the ha, but it didn't help much by itself.

For those of you who work ER, please remember this...sometimes a patient with a migraine is really a patient with a migraine. We are not all drug seekers. AFter my first ER visit with the migraine, I wondered if I would have been treated less like a drug-seeker if I had just taken in a bag with my current narcotics in it and said "I don't need narcotics, I already have those."? Probably not, probably would have just been mugged by the junkie next door!

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Specializes in ER/SICU/Med-Surg/Ortho/Trauma/Flight.

our protocol is usually the following:

Benadryl 50 IV

Compazine 25 IV or phenergan 25 IV

Ketrolac 30 IV

Norsaline 10 Mls Iv push actually a flush of ns but it seems to work on the drug seekers if it doesnt work then we know your having a migraine and give you 2 morphine IV

1 Liter NS.9

then a head ct and if that doesnt kill you and if you still have a migraine your probabley going to get a lumbar puncture and when we explain what this is to the drug seekers there migraine suddenely goes away

oh and by the way we use Robinul too alot of the drug seekers dont Know what this is but it works about the same as toradol. I also love it when are docs purposely give the drug seekers nubain:angryfire then we have to treat them for withdrawl and I know they do it on purpose sometimes.

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in my ed it would depend on the dr. working..one uses haldol 2.5mg iv with dilaudid 1mg iv and all i have given this to..h/a gone in 15 min. Some others use the toradol 30mg iv and that works well, but the narc. seekers want the dilaudid.

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Specializes in ER, ICU, L&D, OR.
Unfortunately, in our ED the "fix" for migraines is dilaudid and either phenergan or zofran. As you can imagine, we have daily "visitors" that are having "the worse migraine ever". We've spoken to the docs on this and the bottom line is that most can't be bothered with a confrontation if narcs aren't give. I've thought of refusing to give the narcs when we know we're dealing with a drug seeker.

Its easier to treat and street them, rather than go into a confrontation. Then after a confrontation you get letters of complaints that you have to spend time dealing with. Its far easier to give them what they want and send them out the door. Now some of the young docs occasionally get their knickers in a twist and go into confrontation mode. However that also affects us the RNs they use us as intermediaries to pass their beliefs on to the pt and we also get letters of complaint.

Personally I would just rather give them a menu to choose from.

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As a nursing student and a migraine sufferer (Hmmm...could those be related?) I appreciate ANYTHING they give me to make the pain go away! I always self medicate and try to get it under control first!!! Mostly because I don't want to sit in an ER where it is loud and VERY VERY bright! It really burns me though, because if I do go to the ER I am looked at as a "drug-seeker". I have NKDA and do not request specific meds, just please, please, please make the pain stop! I can't stand it anymore. I have thrown up every pill I've taken in the last 2 hrs because the pain is causing N/V!

Sorry..i know this was not really the topic of the thread... Just wanted to remind all...it sometimes doesn't matter what you give the pt....if they truely have a migraine they will be grateful that you made them better! (I do understand that some things don't work for some people...but when they can only take certain narcs, hmmmm?) But, just because I came in c/o severe pain and N/V...that doesn't mean I am one of those people!!!!!!:nono:

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Specializes in ED, ICU, Heme/Onc.

away right away.

I am actually allergic to compazine (I get the extra pyramidal side effects - lock jaw clamped down on my tongue is quite unpleasant - and that was from a PO dose) - and the reglan made me feel like I was jumping out of my skin, but my headache was gone without the nasty narc hangover. The nice nurse got me 25mg of benedryl and I took a little snooze.

So I am the classic 30-something woman who presents to the ER with doting husband in tow c/o "migrane". I'm sure the nurses loved me...:lol2:

Blee

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depending on how well we know the pt (and who the md is): Compazine 10mg, benadryl 25mg, Toradol 30mg - iv- dc iv. I have given haldol, and occasionally narcotics, but most of our migraines, we know.

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our protocol is usually the following:

I also love it when are docs purposely give the drug seekers nubain:angryfire then we have to treat them for withdrawl and I know they do it on purpose sometimes.

Ah, yes, Nubain...That's what the quacky doctor was giving me in my infusion. Except that I'm not a drug seeker...

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Specializes in Emergency.

Yeah but what do you give to a person like me. I took Toradol for an on the job injury- which triggered migraine headaches. Fortunately I have not had to go to the ER for my migraines, but I agree I dont want to be all drugged up, I just want the pain gone. The side benefit of working ED/EMS for 18+ years is that my home bag of tricks is pretty large. For example one gets weird looks from the spouse when brewing/ drinking a pot of strong coffee, taking a couple tylenol PM, and either ibuprofen or naproxen. Fortunately I dont get much nausea.

Course in those years I have seen the various cocktails the other posters have mentioned. But as one neurologist told me the key is if the triptans dont work, you need to knock them out for at least 10-12 hours.

RJ

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i'm a traveler so i see ALL of the treatments...........the best working so far is reglan/benedryl/1 liter .9ns

so sad this isn't used everywhere................so sad i can't talk the docs into it.

patients really are very very happy after this.........

Jen

We have many different doctors and no policy but you are right one of our doctors use this and it works on the real ones. The others whine. We still have doctors who give narcotics freely because they hate the whine.

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Specializes in OB, lactation.

Personally I would just rather give them a menu to choose from.

From what I understand of migraines (which isn't a whole lot, but still...) that may be the best idea. There are various kinds of migraines and different solutions work for different people. I know there are lots of drug seekers, but I don't think it necessarily means someone is faking if a certain thing doesn't work.

When I had my first migraine about 7 years ago (around age 28), I went to my small town ER just to make sure I wasn't dying... they gave me Imitrex which must have been the one thing in the world that could possibly make me feel worse.

I'd had a CT, knew I wasn't dying, and so my husband just took me home(without an offer for any other help from ER). I know they probably thought I was a drug seeker. It continued for about 5 more horrible days after that - but hey, they didn't indulge a drug seeker!

Luckily I've never gotten one that bad again, it happens about once a year with prodromal signs ('aura' - distinctive zig zags in my vision)... another doc gave me a few codeine and I can usually head it off if I pop one real quick as soon as I see the zig zags (the bottle of probably 10 pills has lasted years... they have probably turned inert or poisonous at this point!). If I don't get it within about 5-10 minutes of the aura, forget it. Motrin has worked the same way a couple of times when I wasn't home (knock wood, they seem to get less severe over the years). Like someone else said - I just want anything that will work! Chanting, witch's brew, who cares, as long as it works!?

I don't know if anything else would work for me because I haven't tried and don't have them often. I am curious about the benedryl / reglan combo - anyone know offhand how those pharmacologically/physiologically work for migraines (just curious)? (edit... I found the answer, for reglan anyway: http://www.emedicine.com/emerg/topic230.htm ...there is a connection with dopamine & reglan, compazine, and haldol are dopamine antagonists)

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