ask the pharmacist
By Benjamin W . Friedman , MD , MS , FAAEM , Guest Columnist
Emergency Treatment
QHEADACHE IS THE FIFTH most common reason
for a visit to the emergency department , and migraine is the most frequent headache diagnosis made in the emergency room ( ER ). 1 In fact , 6 percent of Americans with migraine visit an ER annually for migraine-related pain or complications . Of that 6 percent , one-third visit the ER two or three times a year and one-fifth visit four or more times per year . 2
Emergency physicians are not the ultimate resource for long-term headache management . It is best to discuss headaches with your primary care provider or schedule an appointment with a headache specialist who has more training and daily experience helping patients with difficult-to-treat headache disorders . That said , if your physician is not available , the ER is a reasonable place for expedited diagnosis and treatment , particularly if you ’ re experiencing a thunderclap headache ( the most sudden and intense headache you ’ ve ever expeirenced ) or severe headache with fever ( which could be indicative of a ruptured aneurysm or meningitis ).
It is common practice in the emergency room to administer intravenous ( IV ) fluids for acute migraine . The nausea and vomiting that accompany migraine often dehydrates the patient . Plus , IVs just seem to make patients feel better .
To ensure medication is absorbed into your system quickly , an ER physician may administer a drug via an injection , intravenous catheter or rectal suppository . These delivery systems bypass the gastrointestinal tract , which is particularly useful if associated nausea and vomiting are a problem .
Often , emergency physicians will treat headaches with migraine-specific agents such as Imitrex ® ( sumatriptan ), nonsteroidal anti-inflammatory drugs such as Toradol ® ( ketorolac ), and antiemetics
What kind of treatment can I expect from the ER ?
such as Compazine ® ( prochlorperazine ) or Reglan ® ( metoclopramide ), which ameliorate the migraine and treat associated nausea and vomiting .
Demerol ® ( meperidine ) or Dilaudid ® ( hydromorphone ), two types of opioids , are the most commonly used to treat migraine in emergency rooms ( they also happen to be the most commonly used opioids in general ). However , some emergency physicians are reluctant to use these as a primary option for fear of exacerbating the underlying headache disorder . 3 Opioids are also highly addictive .
Occasionally , patients who require stronger medication ( such as opioids ) may clash with their emergency physician over this issue . For this reason , people who experience frequent headaches and may need to visit the ER should maintain strong relationships with their primary care physicians or headache specialists . Those physicians can advocate for patients in these situations . Keep in mind that if your headaches are so severe that you are making regular visits to the ER , it is time to see a headache specialist for a more proactive treatment plan that addresses both preventive and abortive means .
If you do need to go to the ER , alert your headache specialist that you are going . The specialist can advise the ER physicians about which medications work for you . It may also be worthwhile to have your physician help you create a contract documenting your headache history and detailing your treatment plan and goals so that you can take that information with you to the ER . These actions should help decrease the scrutiny you might otherwise receive . HW
BENJAMIN W . FRIEDMAN , MD , MS , FAAEM , is associate professor of emergency medicine at Montefiore Medical Center and the Albert Einstein College of Medicine in the Bronx , NY .
1 . Evans et al . “ Headache in the Emergency Department .” Headache . 2011 ; 51 ( 8 ): 1276-1278 . 2 . Friedman et al . “ Use of the Emergency Department for Severe Headache . A Population-based Study .” Headache .
2009 ; 49 ( 1 ): 21-30 . 3 . Vinson . “ Treatment patterns of isolated benign headache in U . S . emergency departments .” Annals of Emerging Medicine .
2002 ; 39 ( 3 ): 215-222 . www . headaches . org | National Headache Foundation 13