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