Alternatives to the ER
In an earlier feature, we explored complications of migraine that deserve immediate attention in an ER setting. No doubt that article left you a lot of questions, not the least of which went something like this:
That’s great to know, but what about those times
when the pain is so unbearable I can’t take it anymore?
Well, that’s a very good question. You see, not all headaches are migraine. Sometimes we need to get emergency care for what we think is migraine just in case it’s something else.
Some other reasons to visit the ER:
- Any headache symptom that is new to you
- The worst pain you’ve ever experienced
- Severe head pain with fever and stiff neck
- Severe headache that starts within a few seconds
- Severe headache after a fall or blow to the head
- Headache accompanied by double-vision, vision loss, weakness, or confusion
Most visits to the ER for headache or migraine are a result of patients who have experienced prolonged pain and have reached the limit of their ability to cope3. While a visit to the ER may be reassuring that nothing life-threatening is wrong, few patients get lasting relief. It is common to experience a recurrence of pain within 24 hours.
In A Neurologist's Guide to Acute Migraine Therapy in the Emergency Room, Drs. Amy Gelfand and Peter Goadsby write,1
"It must be stated at the outset that an ED visit for migraine represents a failure of appropriate outpatient management, and modifications in the patient’s rescue plan need to be made to avoid such visits in the future."
My own experience reflects this reality.
The number one problem I encountered was the absence of rescue treatments I could use at home1. I would reach my limit, give in and go to the ER. There I would get the exact same treatment every single time. I was using the ER as my rescue treatment. There was nothing special about the medicines I received. They were not controlled substances either. The treatment worked nearly every time. Those very same medicines are available by prescription for home use.
I’ve been seeing the same PCP for 18 years and I didn’t know I could get those medicines administered at his clinic until just four years ago. Then just 3 years ago, I finally talked to my headache doctor about the need for such treatment at home. He was very willing to help. Having access to rescue medicines at home has completely eliminated any need to use the ER for migraine treatment.1,3
I’m one of the lucky ones. Many of you face daily, unrelenting pain. There are treatment options available to you, but the ER isn’t the best place to get that kind of treatment. ER doctors are not headache specialists. Unfortunately, there isn’t even an established protocol for the treatment of migraine in the ER. Each hospital (and frankly, each doctor) uses his or her best judgment. If that judgment is based on stigma-loaded myths, then you are not likely to get very far by going to the ER.
What you may need is either an inpatient stay at a headache clinic or a very skilled headache specialist who can arrange for you to get IV infusions of just the right medicines on an outpatient basis. Unfortunately this kind of treatment is only available in a select few specialty clinics. You and your headache specialist may have to get creative if the ideal course of treatment involves multiple days of IV infusions.2
Some medications used in infusion therapy:
- magnesium sulfate
- dexamethasone (brand name Decadron)
- valproate sodium (brand name Depacon)
- droperidol (brand name Inapsine)
- metochlopramide (brand name Reglan)
- dihydroergotamine (brand name DHE45)
- promethazine (brand name Phenergan)
- tramadol (brand name Ultram)
- levetiracetam (brand name Keppra)
A few summers ago, I needed 3 days of Solu Medrol (steroid) infusions to stop a bad round of cluster headache attacks. My doctor arranged for me to get treatment inpatient at our local hospital. I had to complain loudly and frequently to get past his gatekeepers, but I finally got through to him…at least my husband did. I was too far gone, sucking down oxygen, pacing a hole in the floor, and beating my head against the wall.
You think I’m joking? Nope, that’s literally what a bad round does to me.
Getting this kind of aggressive treatment is difficult at best, even when you know it’s what you need. It can take a lot to get doctors to understand how bad your pain really gets. Hopefully you can have a conversation with your doctor before your situation becomes dire. If the two of you can agree on a plan, then you are more likely to get what you need, when you need it.
It may take some creative thinking though. In the absence of a 24/7 “migraine infusion center,” you may have to accept an inpatient hospital stay. However, there is always the possibility that you can get IV therapy at another type of infusion center (such as the kind that administers chemotherapy or dialysis) or have your doctor arrange for a home health nurse to visit you to administer the medications. These kinds of plans are a bit unusual, so it may require a lot of lead time to get the necessary insurance authorizations. Talk to your doctor well in advance so he or she can make these arrangements.
Should you have a good rescue plan in place, there might still be a rare occasion when your headaches are so severe that you do need to use the ER. The ER doctor might want you to have a CT scan or MRI.3 As long as the migraine attack is typical of what you normally experience, these tests may be unnecessary. You do have the right to refuse this testing and still have your acute pain treated appropriately. The day after you receive treatment in the ER, it is important that you follow up with your doctor. He or she may want to adjust your treatment plan to further reduce your risk of a return trip to the ER.
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