Migraine Treatment in the ER
Going to an emergency room with migraine is a nightmare. It’s loud, bright, smelly and chaotic. Health care providers may suspect that you’re not really in pain, but are looking for opioids (narcotics). The treatments aren’t any better than what could be given in any doctor’s office (as long as your doctor offers them and can see you in a timely manner). Yet, migraine accounts for more than 800,000 emergency room visits in the U.S. each year. A study published late last year examined why.
Are you thinking, “They didn’t have to do a study for that; I go to the ER because I’m in pain and I have no other way to stop it”? That’s pretty much what the researchers found: patients consider such severe pain to be an emergency and can’t get the necessary treatment elsewhere, but there were some other interesting findings and points of discussion.
Researchers asked 100 questions of 186 patients who met the diagnostic criteria for migraine. These questions assessed demographics, economic status, migraine/headache history, and the severity of the attack that took them to the hospital. The most common reason for going to the emergency room was that patients perceived the migraine/headache to be an emergency or were referred by their doctor. That accounted for 33% of the patients’ ER visits. Other reasons included that the patient’s doctor’s office was closed (20%), they were unable to get an appointment with their regular doctor soon enough (11%), and they had no doctor and didn’t know where else to get help (9%).
Patients who had an attack of similar severity in the past and/or had previously been diagnosed with migraine were just as likely to go to the ER because they thought it was an emergency or their doctors had told them to go as those who hadn’t been diagnosed prior to the visit. This was of particular interest to researchers because, presumably, patients who had been diagnosed with migraine know that it is not a life-threatening emergency.
Patients go to the ER for many reasons: severe pain that doesn’t relent with any treatments you have at home, vomiting so frequent that dehydration becomes a risk, not being able to get on their doctor's schedule, a lack of insurance or an established relationship with a doctor, a frightening change in their migraine frequency or severity. This study identified many of the reasons other than fear that people go to the emergency room for migraine. It does not say that patients should never go to the ER for migraine, but that many in this study did because they thought it was an emergency. Because of this, one major point of discussion was the disconnect between doctors telling patients that migraine wasn’t an emergency and people still going to the ER because it seemed like it had to be. That last part is what caught my eye because I think it highlights and interesting disconnect between patients and doctors.
Even if we have a diagnosis and our doctors have told an attack is not an emergency, both those things can be hard to believe. Attacks feel so violent that it seems impossible that they could be caused by something most of us are told is just a headache. How could something so painful and disabling not be life-threatening or at least very, very serious? Since there’s no way to see migraine, no test to prove a person has it, we have to go on our doctor’s word that, based on our symptoms and family history, our lives aren’t in danger. We have to believe this even though the symptoms of an attack feel just like the body is screaming, “Danger! Danger! Get help now!” If a doctor doesn’t recommend an MRI or CT scan, many patients remain convinced that their doctors are missing a brain tumor or aneurysm. Even with brain imaging, we still worry our doctors are missing something.
Society tells us that either headaches are not big deal and can be relieved with OTC painkillers or that they are a sign that we’re about to die from brain tumor or aneurysm. Common beliefs about headache don’t allow for severe, recurrent pain that isn’t life-threatening. And because headaches aren’t thought to be a big deal, many of us don’t mention them to a doctor until we’re scared they’re a sign of something serious. Most of us don’t get a migraine diagnosis until we’re already freaked out—and it’s hard to be reassured by words from a doctor when what’s happening in our bodies feels so wrong and frightening.
On the surface, the problem seems like one of patient education—that if doctors educated their patients about migraine, then patients would understand they don’t need to go to the ER for an attack. That is probably true for some of us, but I think the problems are deeper than that. Public perception plays a large role. If there were widespread knowledge about what migraine is like, not everyone would automatically assume an excruciating headache equals a brain tumor or aneurysm. It’s also a problem of meager funding for migraine research. If scientists understood exactly what was happening in the body with migraine or why, there’s a chance a test could be developed to identity those things in the body. And, of course, there’s fear. Even with education and public knowledge and tests, it will probably take most patients a while to believe that something that feels as awful and abnormal as a migraine attack is not an emergency.
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