Migraine & The ER — A Follow-Up Interview
Ellen – Hi Dr Kingsley, and welcome back to the Migraine.com community!
First I would like to thank you for volunteering to contribute your expertise and knowledge to help Migraineurs better understand the emergency department (ED) from the physician’s perspective as well as learn how to get better care in the emergency department when they are there for a migraine attack.
Your articles Migraines From An ER Doctor’s Perspective and ER Strategies For Migraine Relief created quite a lot of discussion in the Migraine community, some positive and some well, not so positive.
I’m very happy that you agreed to come back and help the community better understand your physician’s perspective. It is my sincere hope that this interview will help everyone should the need for an ED visit be necessary. And generating some positive, constructive discussion would be fabulous too!
Dr. Kingsley – Many great points were brought up and I’d love to contribute.
First, I would like to thank everyone for their contributions and questions regarding my posts that you mentioned. I definitely need to refine several of the things that I wrote (thanks again for the thoughtful replies). Many of you have had utterly horrible experiences with terrible migraine disease. I hope that you are all someday migraine-free.
Ellen —One community member asked “”Fortunately there are so many alternative treatments for migraines. ” What are some of the “so many alternative treatments” that are given at the E.R.???”
Dr. Kingsley – I do not support CAM (Complementary and Alternative Medicine) as the primary treatment in migraine in the ER– although acupressure does work for many in this setting. I think CAM does have a role in adjunct therapy. There are seldom the resources in most ERs to make this happen. I actually studied acupressure as an adjunct therapy back in residency, and it was often effective!
As far as medication options in the ER (other than opioids) here is my partial list. These medications are often used in combination:
- Triptans — Imitrex, Maxalt, Amerge, Zomig, Frova, Relpax, Axert etc. Sometimes one doesn’t work, but another will. Some are not on formulary at hospitals/ERs because they can be SO expensive.
- Toradol (this alone works for some)
- Other NSAIDs (many patients haven’t even tried this prior to arrival in the ED)
- Dexamethasone or other steroid regimen… this is likely more helpful the next day
- Ergots— We seldom use these. We are able to use DHE in our emergency department, but I am quite certain you will find places that do not offer this treatment. In addition, because it is a less common treatment, you will find physicians are less comfortable using ergots. I use it very rarely (it has been many months).
- Antiemetics – Zofran, Phenergan, Compazine, Reglan or other antinausea medications. Again — sometimes one will work where another fails.
- Fiorinal, Treximet or other combination meds, not as effective in my experience during acute decompensation and they will often cause rebound headaches. I don’t use these.
- Butyrophenones/neuroleptics— such as droperidol or haldol, administered with dexamethasone, benadryl or Cogentin,and a benzodiazepine (Ativan)— all IV. This combination is a cornerstone in my acute migraine treatment with phenomenal success rates. Studies show 87-89% success rate in migraines with droperidol alone. It is exceedingly rare that true migraine disease doesn’t respond to this– even very complex symptoms.
Not all ER doctors are comfortable using all of these medications and they are not required to use something with which they aren’t comfortable. All medications have risks, some larger than others. Talk to your doctor or neurologist about an ER treatment plan. If you find a combination that works– have someone write it down so you can use it next time!
Ellen — I like that your first line medications actually work to help abort the Migraine process itself, as we all know if the Migraine ceases, so does the pain. The pain drives us as patients, and we often enter the ER with only the incredible pain on our minds. Nothing else much matters to us at that time, which is unfortunate. We say “Make this pain go away” when we should be urging the staff to help us abort the process that causes the pain.
Dr. Kingsley – I see two separate issues 1) pain treatment 2) workup/evaluation. Number 1 should happen quickly, although it can complicate the workup– especially if you are worried about the patient and their neurological exam is vital to their ongoing workup. If you sedate someone profoundly with medications, it can eliminate one of the best tools we have– the neurological exam. This is very important in the setting of strokes. This is one source of conflict– although someone may be in ongoing pain, there may be situations where heavily sedating migraine treatment must be delayed to protect even more important things– like the patient’s ability to speak or walk. Clear as mud although this is a pretty rare situation. When someone is in excruciating pain, things are black and white. On the other side– with a ton of experiences, many of them bad, things are not so clear.
Ellen — That makes a lot of sense. That said, I am curious if you have considered IV therapy that includes magnesium sulfate, valproic acid or other medications in Migraine patients in the ER setting which don’t tend to be as sedating? Can you comment about them?
Dr. Kingsley — Yes, that was a partial list and I definitely forgot magnesium. I use a single IV dose of magnesium sulfate as an adjunct therapy and I think it is helpful in migraine with aura, particularly if a patient’s magnesium level is low. There is evidence of its effectiveness as a lone medication in migraine with aura, but there is also substantial evidence that others are superior (neuroleptics and others) for acute migraine. I tend to be aggressive and give my usual, sedating medication combinations that is very efficacious. I try to do this right away during the patient’s ER visit. In migraine patients with aura or menses-associated migraines, magnesium sulfate is part of this treatment. I would not give what I see as an inferior treatment (magnesium alone) to someone (i.e. hemiplegic migraine), just to have a better neurological exam. When in doubt we will get imaging studies to protect the patient—while almost always destroying their migraine (and hopefully any associated neurological signs and symptoms) with our sedating combination of medications.
With regard to valproic acid, I am not comfortable using this as a primary treatment for acute migraines in the ER. If someone with very difficult migraine disease came in with a care plan that contained valproate, I would use it in that case. The studies I have seen, when taken as a whole, are not convincing to me. For prophylaxis I think there is much more substantial evidence that it works. Of course, like many things, there is much anecdotal evidence that valproic acid works for some migraine patients. If someone came in and told me “I need valproic acid for my migraine, it has worked in the past”, I would also do it.
Wow, great questions Ellen—you know your stuff.
Ellen – What is the “average” Migraineur that you see in your particular Emergency Department?
Dr. Kingsley – I know that many people on this forum are not representative of the “average” migraineur that I treat in the ER. It is not uncommon for us to see migraine or other headache patients who have tried nothing to treat their symptoms. For many here, I know that seems unusual but it may help you understand our perspective. The most common migraine complaint that I see in the emergency rooms in which I work is not “the worse headache of my life” or anything out of the usual for the migraineur. Most frequently we see people who are having their “usual migraine”. I would say this is at least 90% of the migraineurs we treat. Most are not seeing a specialist and their symptoms are many are not being managed effectively by their primary doctor (if they have one). Some are not even really migraineurs and have yet to be appropriately diagnosed. Some are uninsured and can’t afford their meds. I have found nearly universal success in giving substantial relief to these patients in the ER setting without the use of opioids. It is quite refreshing (and not too common) when someone comes in who is well informed about their migraine disease. I haven’t seen a migraine care plan in many months.
Ellen—I noticed a few people expressed concerns about repeated extensive work ups and imaging for strokes in the ER for difficult syndromes such as hemiplegic Migraines. Is this pretty standard?
Dr. Kingsley – When a migraineur is unfortunate enough to have the “worst headache of her/his life” or other out of the ordinary symptoms (in general, not just for the individual patient), this will almost universally trigger a more extensive workup (CT, MRA or lumbar puncture etc). When someone is so utterly unfortunate as to have objective neurological findings (hemiparesis – weakness or paralysis on one side, disconjugate gaze – failure of the eyes to turn in the same direction, etc) they will almost certainly be scanned in the ER. No matter how typical this is with your migraine, it will be very difficult to convince your ER doctor that you don’t need an CT and/or MRI. This is because you are at increased risk for stroke (almost all strokes have neurological symptoms associated with them) and it is a line past which we are uncomfortable. I have scanned a few hemiplegic migraine patients in my career, and I can remember at least one that had a definite stroke with subsequent long term disability- although this patient had symptoms that were much, much worse than her usual migraine associated symptoms. I have also been talked out of several MRIs by migraine patients with their “typical neurological deficits” associated with their migraines. They were in general pleased and treated effectively in the ER. I was able to have in depth discussions with them regarding their care despite their discomfort. I would not be comfortable forgoing a workup in these cases if I am not able to really form a connection with these patients and their families. I would never presume that all my migraine patients are the same– it would be unwise for patients to assume all ER doctors are the same.
Ellen — Does the number the patient reports on their pain scale affect the choice or type of treatment the patient receives in the ER?
Dr. Kingsley – A few very insightful folks posted that our perspective on someone else’s perceived pain shouldn’t change a patient’s treatment. This is very well put and I agree– in an ideal world, we would treat all truthful patients exactly the same. I am just trying to maximize your chance of an as-little-pain-as-possible ER trip. I think it would be quite unlikely that any treatment decisions will be changed based on your “pain number”. However, a dramatic, off-the-wall, swearing, “12 out of 10” may be treated differently than the obviously miserable, but calmly stated “9 out of 10”. Just trying to come up with an example… I can honestly say that I would treat these two with the same migraine regimen. Pain should be treated as promptly as possible, no matter the cause. However, if you are a complex case and communication is going to be vital for you to receive good care, it is very helpful to do everything you can to facilitate open, clear communication with your care team.
Ellen — It might be helpful for patients to understand the kind of #10 pain you have seen as an ED physician…
Dr. Kingsley – This is tough—because it is so subjective. “Kidney stones” are pretty consistently an 8 or 9 for most, full-body burns if not too deep (that kills the nerves), Child birth has to be up there?—although some women say kidney stones are much worse. These are just some of the most painful non-headache examples. Cluster headache patients in general seem objectively miserable.
Ellen — You state “However, a dramatic, off-the-wall, swearing, “12 out of 10” may be treated differently than the obviously miserable, but calmly stated “9 out of 10”. What would you do differently for this patient beyond the scope of additional testing?
Dr. Kingsley – I don’t think there should be any different medical treatments or testing. The problem arises in that the medical team-patient interface is a human one. We have to get the patient registered, we have to get a history, an IV must be started. All these things would go more smoothly with the calm patient.
Stroke and Death
Ellen — Let’s talk about those rare instances when Migraine can result or contribute to the death of the patient. I don’t want to start a discussion on suicide today — we’ll save that for another time, but some in this community have had experiences with patients and Migrainous stroke or other complications related to their Migraine attack that resulted in permanent injury and/or death. This is why we try to inform Migraineurs of the full spectrum of Migraine — meaning that there are some patients with Migraine for whom an acetaminophen tablet is enough to get them back on track, while others may require hospitalization, or yes – that it can be fatal. We feel that it is irresponsible for us to leave out the subject of Migrainous stroke when we educate patients about Migraine.
We understand that emergency departments have to prioritize life-threatening injuries and conditions. This is called triage. What seems to be missing is the acknowledgement that Migraine can be a life-threatening condition — however rare. Can you explain how triage (and re-evaluation in triage) is done in the ED and how we can help ED staff if we are truly concerned that our Migraine attack might be of the dangerous variety or may be contributing to another serious condition?
Dr. Kingsley — I very much see your reasoning for teaching the spectrum of migraine disease. If someone is having a “different” or new migraine, it is vital that they be informed of what can happen. It is vital to immediately seek medical care. If during the course of a migraine event, you suddenly are not able to speak or have other unusual symptoms that have never happened before—call the ambulance. The other side of this coin is that I do not feel it is helpful for every migraineur who is having their completely typical migraine event to think that their life is on the line. Acute recurrent migraine is almost never a life-threatening event, especially if the patient has no neurological symptoms and the symptoms are consistent with previous migraines. I know you and many of the migraine.com users are not typical cases. (I know this is a contentious point, so I made sure to have my colleague who is migraineur, and board-certified in both neurology and emergency medicine read this response—she agrees with my statements.)
If you feel your new symptoms are being ignored– you MUST advocate for yourself. Tell your doctor and nurse “I’m worried, this is NOT normal, this is NOT my usual headache”. Any team worth anything will listen to you.
As far a reevaluation goes– for me it is very important that a patient responds to an aggressive migraine medication regimen in the ER. If they don’t respond within 30-60 minutes or so, I tend to push for a more in depth work up. Our ER tries to reevaluate patients every 15 minutes. In triage– I know there are places that have 30-40 hour wait times. I’ve worked at places like that (our current average triage wait is 10-12 minutes). Long wait times are trouble. Unfortunately there is no great answer to inner city ER overcrowding. Often times there are only limited resources available for reevaluating patients that are waiting in triage.
Ellen – Dr. Kingsley, do you or anyone that you know in your personal life suffer from Migraine Disease.
Dr. Kingsley — I definitely prefer to maintain the caregiver role on this forum. I have many friends and family members who suffer from migraine disease or other headache disorders. I have a sister who suffers from chronic daily headaches. I have colleagues who are incapacitated frequently by migraine disease. It really seems like it is everywhere. Neighbors, teachers, politicians, athletes… strange more resources aren’t going toward this problem.
Ellen — What comments or advice do you have for Migraine patients to help mitigate any stigma we might find in the ER?
Dr. Kingsley — It is frequent for we as humans to internalize things and take them personally. Do not assume that the short doctor or grumpy nurse thinks that you are a “drug-seeker”. When in severe pain it is almost impossible to think outside of ourselves. Say to your team– “I will try anything to get rid of this headache”. How can someone not listen to that?
Ellen — If we feel that we have not been treated appropriately in the ER, where should we turn?
Dr. Kingsley – In the short term, it is vital that your primary doctor or headache specialist advocate for you. Call them or their partner on call. Have them call the ER and confirm your care plan. If you think the situation is impossible, go to another ER? In the long term, call the patient representative for the hospital. Everything in medicine these days is driven by patient satisfaction. If particular staff is an issue, others will complain too and things will change.
Ellen – Thank you so much Dr Kingsley for taking the time to keep this conversation going with our community! Of course there is no way we can cover everything here in one short interview and I invite community members to ask any other constructive questions they have that we might not have hit upon. It is my sincere hope that we can use this to get some useful, constructive conversation going that will help patients should they find the need for an ER visit in the future.
Okay folks, now is your chance to ask questions. This is a hot hot hot topic, so please keep your queries respectful, positive and constructive so we can all hopefully learn something that can benefit us either personally, or as a community…. If you’d like to see Dr Kingsley address something we’ve missed here, I hope you’ll mention it just in case we can convince him to come back another time. 🙂
Dr. Kyle Kingsley is board certified with the American Board of Emergency Medicine and a member of the American Headache Society. He currently practices emergency medicine in multiple hospitals in the Midwest. His interests include his two young children, health/fitness, triathlons, and Eastern medicine, particularly when it is applied to chronic health issues including chronic headache conditions. Dr. Kingsley studied acupuncture and alternative medicine in Cuba in 2003. He also presented his unpublished study “Acupressure in the Treatment of Benign Headache” at the Society for Academic Emergency Medicine annual meeting in 2005.
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