20 November 2007

Small Victories

The triage note was not encouraging. "Migraine. History of same x 10 years. Workups included (-) CT, MRI scans. Has had daily migraine x four weeks. Pain not relieved with Imitrex today." A quick glance at the previous visit list revealed a number of ER evaluations for headaches, though not too many. He usually got dilaudid for his headaches.

"Migraines" suck the life force out of me. They are rarely in fact, migraines, but simply tension headaches versus undifferentiated headaches. The frequent headache patients usually require large doses of narcotics to "fix" and have strong affective components to them (I've cured a few migraines with ativan, an anti-anxiety medication which has no pain-relieving properties). There are many frequent headache patients who are simply seeking drugs. I try to avoid narcotic meds when possible, because of abuse potential, because they often provide only short-term relief, and because they can induce rebound headaches.

This guy seemed nice enough. He didn't present the dramatic emotional display that many faux-headaches show, and he was a somewhat unusual headache patient in that he was a) male and b) gainfully employed. I offered him the same initial treatment I do any other benign headache: toradol, a non-narcotic pain reliever, and some vistaril, an anti-nausea medicine. I braced myself for the inevitable objection: "That doesn't work for me" or "Oh, I just remembered, I'm allergic to toradol." But it didn't come. He had never heard of it, and apparently trusted me enough to give it a go. So I ordered the meds and went off to see the next patient in the queue.

Forty-five minutes later I dropped by his room to see how he was feeling. He was sitting up, with the lights on, rubbing the back of his neck with a look of amazement on his face. "Doc, I don't know what it was that you just gave me, but it was magic! I feel better than I have in weeks!" His wife wondered why no ER doc had ever given it to him before.

He went home happy and feeling well, and I went to see the next patient with a smile on my face. It's so nice when things work like they are supposed to...

13 comments:

  1. Had a "migraneur" last PM. Very similar presentation - "HA for days, vomiting, photo/phonphobia, etc..." Mult prior visits to our ER in the past (5 in Oct.) PMD is well known for being shall we say - liberal - with the narcs. Totally normal exam. I told pt I would treat with fluids, phenergan, and non-narcotic pain meds. Pt. stated, "if you're not going to give me narcotics to treat my pain, then I'm leaving." Left AMA before I could even type up her dc instrucytions - I love it when they don't waste my time! Clears up her bed for another pt.!

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  2. There's a question, though: why is it that other ER docs might not have tried your regimen? It seems like there's a mysterious sweet spot, in between "oh, I'll just give 'em the narcs" and "no soup for you!"

    I suspect the answer is the frustrating fact that what works for one may not work for another, but still.

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  3. Thanks for this post!

    Have seen an increase in the severity and length of my migrines. It's totally stress related I know. Don't take any meds for them other than my sure fire cure of #1- Can of Coke #2-4 Alleve #3- Chocolate. They used to vanish within 20 minutes of taking the above mixture, but lately that is not doing the trick.

    If they continue to get worse I'll see if the meds you mentioned might do the trick.

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  4. Uggg...migraines! I know how to spell!

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  5. So. I'm female, gainfully employed, have photo and phonophobia, and have had the same migraine for 4 weeks. Toradol does not work for me, and the triptans have lost their effectiveness.

    Does that make me a drug-seeker? I'm a bit frustrated by your writeup, because although I acknowledge that there are people using migraine as an excuse to get narcotics there are also people out there with intractible untreated pain. It's a conundrum. I don't want narcotics -- I want something that makes me functional again. I would happily sniff powdered cat up my nose if that worked.

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  6. Hi,

    Thanks for the post on migraine- it is always nice to hear about good migraine treatment.

    I have one question:
    Why is it that patients with migraine seem to have a bad reputation in Emergency Medicine?

    I understand that migraine is sometimes hard to treat and there is no conclusive test for it. I also understand that some patients may use "migraine" as an excuse to get medication, but I think that number is probably in the minority.

    I am currently in graduate school and also dealt with this through college.

    I have battled complicated, refractory migraines with occasional neurological symptoms (slurred speech, double vision) for ten years now. I have a very good neurologist and rarely have to use the ER. However, when I have had to go it has always been under the orders of my neurologist. Even then, I have been told that I am simply a "drug seeker". I now have a letter stating the nature of the problem, what works, etc. But the worst part of the ER is never knowing how the dr will react to an invisible and painful disease.

    I am sorry that the post got a little long, glad that you were able to treat the migraine patient, and would love any response to the question of why ER drs find migraines hard to treat.

    thank you.

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  7. Doc R neurology ny11/24/2007 8:00 AM

    The problem with treating migraine patients, or any other condition that may require narcotic pain meds, it that most doc's have been burned/fooled simply for a fix. That experience can carry alot of emotional weight, no different than having your house or car broken into - you feel violated.

    Sure there are many legit headache patients out there who need the occassional demerol dose, but the key it keeping them out of the er. There are medications that can be used to knock out the headache at home such as thorazine or stadol under a docs guidance.

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  8. My sister had a splitting headache followed by temporary right-sided paralysis (including slurred speech); she's only twenty, but she had a surgical procedure to fix a hole in her heart as a child that apparently increases her risks of blood clots.

    She gets a full neurological work-up; the MRI is "mostly clean."

    She was discharged with a working diagnosis of "complex migraine."

    Although the MRI showed past TIAs and possible demyelinization.

    Anyway. Yeah. That's one scary-ass migraine.

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  9. hannah:

    technically a complex migraine would involve the paralysis occurring prior to the headache. if she has a history of migraines in general, she is more likely to have small white matter hyperintensities which is neither demyelination nor a tia (tia by definition doesnt leave damage that is seen on an mri)..these are usually of no clinical significance

    but yes, definitely a scary experience

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  10. Dr. - hey, thanks for replying. I'm curious because most of the results of her spinal tap haven't returned yet...not that anything may come of them, anyway.

    I'm not entirely sure about the paralysis before the headache, just that she was discharged with complex migraines as a possible diagnosis.

    She doesn't have a history of migraines, although there is a family history of them. (I've had them occasionally since I hit puberty, but never like what she experienced.)

    I know that TIAs are a possibility with her because of the surgery that she had to correct the hole in her heart. (Her heart ultrasound was clean, however.) I was always under the assumption that a TIA wouldn't show up on the MRI, so I'm not entirely sure what that's about. Just relaying what my mother reported to me.

    Obviously, your explanation rocks because, y'know, possibly having MS would suck.

    Anyway, thanks again for the information. It's hard when you can't just google something for research -- not an experience that I'm used to having. (I'm not a doctor, but I stayed at a Holiday Inn last night!)

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  11. IF YOU MIGRAINES ARE THAT BAD.......... I would suggest going to the Seymour Diamond Headache Clinic in Chicago. People come from all over the world. I had migraines after a lady hit my little jeep with her big Caddy running a red light. I had a VERY bizarre episode that cured my headaches. I was moving a couch up the stairs and was on the bottom and the guy up top staggared and pushed the couch slightly in my direction and I fell down the stairs. For the next 3 days I felt like I had been hit by a car but ever since I get a 'cluster headache' maybe 4 times a year. The headache clinic did not know what to make of it! I was just glad they were GONE! But the SD Headache Clinic was the BEST! They taught me how to give myself IM injections and that prevented me from having to deal with the ER. GOOD LUCK!

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  12. I had Migraines for about 10 years, pain meds didn't help, and the amount I needed of them to help was enough to make me completely useless, and I was at risk of liver failure from all the drugs I was taking for them. I stared smoking and POOF migraines gone. I ave only had 3 migraines since I started smoking, once when I got my tonsils out, and couldn't smoke for a week, once when I had my wisdom teeth removed, and I couldn't smoke for a week, and once when I quit smoking for a week to see if it was the facial type surgery that gave me the migraines, or the fact that I quit smoking. I've asked my doctor, and he said the average of 6 cigarettes I smoke on a daily basis was far less likely to do irrepaiable damage than the amount of prescribed drugs I had ben on.

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  13. I know the date on this thread is older, but I went to the ER with a migraine a few days ago and was given a combo of Benadryl and Reglan and orders for a CT scan. The meds put me to dozing and helped but what they found on the CT scan was a "craniocervical junction congenital anomaly/asymmetry" and from what I've been told by my family doc who is sending me out for an MRI is that my neck is far out of alingment from where it is supposed to be which is causing C1 in the cervical vertebrae to rub and cause vascular impression. Probably heading for neurology next.
    Migraines suck but its nice in this case to have an ER doc that was willing to look into it and actually helped me find something.

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