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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. KingsleyMany 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.

Treatment Options

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. KingsleyI 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. KingsleyI 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.

Treatment Considerations

Ellen – What is the “average” Migraineur that you see in your particular Emergency Department?

Dr. KingsleyI 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. KingsleyThis 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. KingsleyI 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. KingsleyI 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. KingsleyIt 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.

This article represents the opinions, thoughts, and experiences of the author; none of this content has been paid for by any advertiser. The Migraine.com team does not recommend or endorse any products or treatments discussed herein. Learn more about how we maintain editorial integrity here.

Comments

  • Michelle Stenner
    6 years ago

    How do you treat children with migraine? My 8 year old has migraines quite often (sometimes abdominal, sometimes w/head pain, sometimes both) and I fear the day that it won’t let up and I’m forced to bring her into the ER. I’m a chronic daily sufferer myself, so I have lots of tricks and strategies to help, but when all else fails…….

  • amyw
    7 years ago

    I really appreciate this article. I’ve had many experiences in the ER, unfortunately, both good & bad. I have to say that I have tried NUMEROUS medications, most if not ALL of the ones provided in this article & they don’t work for me. I am a complex patient & narcotics are the only thing that take the edge off for me. I have let them try all types of cocktails on me, but I have found one so far that will knock it down enough to make it bearable.

  • Kristen Newman
    8 years ago

    An IV with Toradol and Zofran is the only medication that helps right now. Do people get standing orders from doctors to be able to go in to the ER for a treatment if it is the oly thing that works? I have been in the ER four times in about 2 weeks and the last doctor seemed frustrated. I don’t want to become a “frequent flier” but don’t know what else to do. I have an excruciating migraine right now and exhausted my home therapies and want an IV of those meds so bad right now, but I have a fear of going to th ER so much.

  • Tina Quezada
    8 years ago

    See you should have come hiking & fishing w/ brandi & I! Im sorry that you have to keep pumping those horrible drugs into your body…..There has to be a way to help w/ your headachs naturally, Im worried about you getting all those all the time, cant be good for you! I hope that you feel better, if I was closer I would come over and hang out w/ you! Love Ya 🙂

  • Patricia Harless
    8 years ago

    Oh,Kristen, hope you feel better. Will pray for you and your doctors. I hope they can find what is triggering your headaches and FIX IT… Love you.

  • Dalene Treadwell
    8 years ago

    I HATE THEM…i get them so bad, within 5 min I’m throwing up, curled up in a cool DARK place..

  • Marcia Bachochin
    8 years ago

    There is nothing I hate more than being treated like a drug seeker. It doesn’t matter how many times I tell them that I am a complex migraine suffer. When I go to the ER I except to be treated with at least a small amount of care. I also expect for them to alleviate my pain. There have been times where they say we can’t do anything for you so I leave still screaming in pain. I have been suffering with these since I was 16, I know what works for me.

  • Roberta Manion Yoffie
    8 years ago

    Hi Marcia, What does work for you? My 17 yr old son has been suffering with migraines since he was 11. We are trying everything, he had Botox two weeks ago. takes 2 IM DHE injections a day at home, Inderal, Celexa and Seroquol daily.

  • Sydney Cole
    8 years ago

    I really wanted to thank you both for writing this. Despite all my best efforts, I generally end up in the ER about every couple of months (I had to go there on my own wedding night!) and it’s always miserable. More than half the time, I doubt my decision to go there… but I always end up back there because I don’t feel like I have any better options right now. So, it’s great to have some good tools in my arsenal that could make it easier from my end.

    Thank you so much!

  • Ellen Schnakenberg
    8 years ago

    It is interesting to note that if you read Dr Kingsley’s list of medications he likes to utilize in the ER, most of them are actually listed on the Medication Shortage lists mentioned here: http://bit.ly/zlDEbM This leaves Migraine and headache patients and their doctors in a really tough spot right now. I hate to think that some ER situations will result in patients receiving opioids instead of more effective medicines because of this shortage situation – although even some of those options are in short supply. I am increasingly concerned what doctors and tough patients like many of us here at Migraine.com will have available to them should the need arise…

  • That M Word: A Migraine Blog
    8 years ago

    Dr. Kingsley and Ellen,

    Thank you for such a wonderful article. Dr. Kingsley, I notice that your treatment plan does not include narcotics such as Dilaudid. This was primarily how my ER doctors treated me during my first few visits, and it ultimately led to the most aggressive rebound migraine I ever experienced. I now request that ER doctors use Torodol or Zofran/Reglan. Why do you think so many ER doctors still use narcotics? Are they unaware of the risk of rebound and simply responding to the patient’s request for pain relief?

    Thanks so much!
    Emily Guzan

  • Elliegal
    3 years ago

    Actually, I hope for me they do resort to narcotics. If mine get to the point where they don’t respond to my abortive triptans, my only option is the ER. Haven’t been to that point in 2 years, but I would hope they would listen when I tell them what works. Although I’m not adverse to alternate treatments, Toradol doesn’t touch my pain and zofran constipates terribly so I’d hate to suffer longer waiting for alternate treatments to not work when I know a shot of nubain will kill it. Ultimately the doc needs to trust the migraineur to some extent, especially if they’re chronic (like me) and have become so familiar with what it takes to manage the disease.

  • That M Word: A Migraine Blog
    8 years ago

    Thanks that was very helpful!

  • Migraine.com
    8 years ago

    Emily – Thanks for your comment. If you haven’t already, you may want to take a look at Dr. Kingsley’s first two blogs, which address the use of narcotics. You will also see from the comments that many patients go in to the ER expecting opiates as their primary treatment (as you noted): http://migraine.com/blog/expert-featured-article/guest-expert/migraines-from-an-er-doctor%E2%80%99s-perspective/

  • Janet Geddis
    8 years ago

    I really appreciate Dr. Kingsley’s taking the time to revisit his original two articles and the readers’ comments. Having had both terrible and mediocre ER visits (never one that I could classify as wholly successful), I have come away from this interview and the original two articles more convinced that I need to get my primary care doctor and/or headache specialist to help me draft an ER treatment plan.

    In regards to the pain ratings: I have been to the ER before with a multi-day migraine and, despite my telling the doctors and nurses that I was NOT in severe pain, that I was there merely because I knew of the dangers of status migrainous, they persisted in prescribing morphine to me. (I stopped them when the morphine needle was inches from my arm.) I know it must be immensely difficult to work in an ER, but if caretakers and patients alike just took a few moments to center themselves before talking to each other, we could save a lot of trouble and miscommunication. In sum: I wish the various ER doctors and nurses I’ve had before had just LISTENED to me. Some visits the pain was unbearable, while during others it was okay.

    Thanks, Ellen, for this article.

  • Teri Robert
    8 years ago

    Dr. Kingsley and Ellen Schnakenberg, thank you for the time and effort that obviously went into this follow-up piece!

  • Stacey Bruhn-Robinson
    8 years ago

    Dr Kingsley,
    I had a SDH 4 years ago and had surgery. I have two burr holes and a plate in my head. No one seems to know how the SDH came about as there was no prior injury. Anyway, since the surgery, I have constant head pain, 4/10 all the time and severe chronic migraines 10/10 two-three times a week. It had gotten to the point where I barely function. I see a headache specialist and I have been on many drugs and combinations of drugs and the only thing the drugs do is make me sleepy and more non-functioning. I have gone through botox and accu-puncture all with no relief. During the migraine, I vomit, I am light and noise sensitive and at times wish for death as the pain is so bad. I am at my wits end. My neurologist gives me vicoden and percocet for prn pain management and sometimes they work and sometimes they do not! I need pain relief. I do not know where to go from here. Every single time I go to the ER I get treated like a drug seeker and sent home with steriods and naproxen. Although four years ago I had surgery on my head and it probably saved my life, if they would have told me about the pain I would endure afterwards, I would have never had the surgery. Any suggestions?

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