Emergent Treatment of Migraine: Should I Go to the ED?
Richard B. Lipton, MD, and Stephen Silberstein, MD, comment on the recommended protocol for patients seen in the emergency department and discuss when inpatient care is necessary for the treatment of chronic migraine.
Richard B. Lipton, MD, and Stephen Silberstein, MD
PUBLISHED November 17, 2018
Current Series: Chronic Migraine Current Treatment Options And Recent Advances
Richard B. Lipton, MD:Many patients with migraine, when their headaches spin out of control, go to the emergency room. The first thing to say about emergency room treatment is that when a patient of mine goes to the emergency room, I always ask myself, “Well, what can I do better to eliminate the need for emergency room visits in the future?” Because the truth is, for patients with migraine, going to the emergency room is a tough experience. It’s brightly lit, it’s smelly, it’s noisy, and migraine causes sensitivity to light, sound, and smell. In addition, understandably, if someone comes in with a heart attack, they get triaged above the person who has migraines, so oftentimes there’s a long wait. So, avoiding the emergency room is a priority.
If we look at what people get when they go to the emergency room in the United States at the moment, more than half of the people who make emergency room visits get opioids, and that is, in my view, a bad idea. And the reason it’s a bad idea is because they don’t kick in quickly. They’re often sedated, so you trade disabling pain for disabling sedation, and of course, the goal of treatment is to relieve pain and restore function, not substitute pain for sedation. And in addition, headache recurrence rates are pretty high with opioids.
So, in patients we don’t know well, we tend to use intravenous metoclopramide [Reglan], sometimes along with Benadryl. And the advantage of intravenous metoclopramide is that it works relatively quickly; it’s not an opioid. The major side effect is restlessness, a phenomenon called akathisia, and giving it with Benadryl is a big help.
In patients we know well, we may use intravenous dihydroergotamine [DHE], along with metoclopramide. We may use intravenous divalproex sodium [Depakote] as an option. There are a number of good acute treatments in the emergency room. Hydration helps; having a quiet place the patient can rest that is not brightly illuminated can help as well. But those are some of the strategies we use here.
Stephen Silberstein, MD: Many patients are considered intractable, and they’ve gone through every medication known to mankind. We offer an inpatient program. We can treat the patient continuously with medications like DHE or lidocaine in an attempt to break the headache cycle. It’s analogous to having a computer that’s not working well and you reboot it. And our concept is, turn the pain off, reboot the patient, and our studies clearly show that about 80% of our patients do extremely well after inpatient admission. We save it for the end of the line. But it’s important to realize that we get many of the end-of-the-line patients here. I believe, at this point in time, we’re the largest inpatient headache unit in the United States in an academic environment.