Frequent Flyers with Migraines

[WerdSalid]

At my shop, headache seems to be the most common complaint among habitual visitors. Headaches seem to rival and even outnumber our back painers. We have several customers who present 3+ times weekly, twice in the same 12 hr shift, 200+ visits per year. Naturally, toradol, other NSAIDS and every triptan under the sun are listed as an allergy. Although it seems at times instinctive to order them their shot of dilaudid and phenergan, this is sometimes more of a knee jerk reaction in order to dispo them quickly and move them along. Our migraineurs come in 2 forms: about 25% occasionally see their neurologist and are the ones taking handfulls of preventative meds like topamax and neurontin. These are the folks that always utter the line "my neurologist told me that if my headache gets bad just to go to the ER." The second are the other problematic 75% who, despite having "migraines" for years on end have never actually seen a neurologist nor seem to have any motivation to visit one. I welcome your thoughts and input. Do your ED's have narcotic policies for frequent flyer headache patients? Does case management ever get involved with these folks in trying to funnel them into a neuro clinic? Do you acquiesce and just give them their shot and send them on their way? Do you just offer compazine, reglan, benadryl IM, etc and take a stand?

---

Members don't see this ad.

 

[southerndoc]

Have you CT'd and LP'd them to rule out SAH?

 

[xaelia]

In theory, at any point with a documented history of repeated visits for narcotics, couldn't you simply diagnose them with Narcotic Dependence, state their symptoms are secondary to narcotic withdrawal, and decline to perpetuate their habitual abuse of D-magic. I suppose it depends how much administrative support you get behind denying patients narcotics and dealing with the potential patient discontent fall-out.

Of course, in the future world of universal coverage, evaluating their acute recurrent neurologic complaint and providing adequate emergent analgesia will actually be compensated. Imagine the competition for these loyal patients when their recidivism is not disincentivized.

 

[WerdSalid]

At some point in time each and every customer to whom I am referring has been CT'd. Most have been LP'd. Some have had MRI's.

 

[Laryngophed]

Have you CT'd and LP'd them to rule out SAH?

Is this the King Solomon approach to frequent fliers? I assume that many of these folks are drug seekers, or I am being overly pessimistic?

 

[Venko]

We have a group of staff (mainly nursing) who coordinate home health and outpatient services for those who attempt to utilize our ED in such a fashion. They work to create standard approaches that they can follow that do not involve the ED and a contract with them for what to expect from the ED if they should come. Everytime they arrive in the ED now, there is a special alert that comes with their chart to draw your attention to the fact that if this visit is the same as the myriad of others, there is an already agreed upon (and hospital supported) protocol for their management.

In general, if they need neurology, they get it faster than others who aren't utilizing resources as heavily who may have the same complaint or other non-urgent neurologic complaints.

One other mechanism by which a neurologist can see the patient is to admit them to neurology or to have a neuro consult in the ED if you think its just about time that they are seen. Obviously different centers can support this option, some cannot, so its an individualized thing of course.

TL

 

[deleted65604]

Of course, in the future world of universal coverage, evaluating their acute recurrent neurologic complaint and providing adequate emergent analgesia will actually be compensated. Imagine the competition for these loyal patients when their recidivism is not disincentivized.

A lot of these patients in my experience are medicaid/medicare/private insurance. You are assuming that we don't want to see them because they don't reimburse us. We don't want to see them because they are dirt-bags.

Do you really think that medicare/medicaid won't find some way to decrease these visits? I suspect that the future of medicine will be a fixed level of annual reimbursement for any given patient that will attempt to dissincentivize these addicts from gracing the ER with their presence.

We've instituted a no narcotic prescription policy for about 10 patients. Even with this known attempt at deterrence, their ER visits only decrease by 25%. You can't forcibly cure an addict, and you can't cure stupid. Most of these people are both.

 

[southerndoc]

You guys are obviously missing my tongue-in-cheek humor. Most drug seekers won't be returning much if they keep getting LP'd (no, I'm not advocating it... was only making a joke).

 

[GeneralVeers]

I rarely give Dilaudid to the Migraine patients. My usual cocktail:

1 Liter of Normal Saline
Toradol 30 mg
Compazine 10 mg (or inapsine)
Benadryl 50 mg

I may add IV Solu-medrol if their headache is particularly severe.

80-90% of the "migraines" get better with this non-narcotic cocktail.

I think Dilaudid for migraine is just poor medicine, as you're giving a heavy narcotic to something that will likely respond to other modalities.

If they have an "allergy" to everything except Dilaudid I look at their visit history. If they have a suspicious history, they may not get anything, or I may just give them an IM shot if they seem legit.

 

[Laryngophed]

You guys are obviously missing my tongue-in-cheek humor. Most drug seekers won't be returning much if they keep getting LP'd (no, I'm not advocating it... was only making a joke).

This is what I was trying to get at, but I wasn't sure. Like King Solomon offering to cut the baby in half, if you offered to LP someone you'd find out just how bad their head hurt. Ok, maybe it was a bad analogy.

 

[Dwindlin]

This is what I was trying to get at, but I wasn't sure. Like King Solomon offering to cut the baby in half, if you offered to LP someone you'd find out just how bad their head hurt. Ok, maybe it was a bad analogy.

If it's any consolation I got it

 

[Apollyon]

Unless someone has a known brain tumor (like a meningioma) or a skull fracture, I NEVER give narcotics for headache. EVER. EVER.

I even saw a patient that had gotten the Compazine, Benadryl, and Decadron, but the doc had also thrown in some Dilaudid.

She came back with a worse rebound headache. I warn patients that the rebound headache will be worse. For the real headaches, they understand. For the drug seekers, they let that idea slide off them like Teflon, but they still don't get the meds.

 

[Laryngophed]

If it's any consolation I got it

Knowing that in a few months I'll be so low on the totem pole, the ground will look down on me, I'll take what I can get!

 

[deleted6669]

You guys are obviously missing my tongue-in-cheek humor. Most drug seekers won't be returning much if they keep getting LP'd (no, I'm not advocating it... was only making a joke).

I know of one facility with an em residency that decided that their residents needed more lp's so they adopted this policy(in all seriousness):
before receiving narcotic therapy for a recurrent h/a each pt shall have a lumbar puncture regardless of when the last one was performed. their frequent flyer h/a population went way down...imagine that....they didn't ct them every time, but they did get a daily lp if they showed up daily....

 

[Stitch]

I rarely give Dilaudid to the Migraine patients. My usual cocktail:

1 Liter of Normal Saline
Toradol 30 mg
Compazine 10 mg (or inapsine)
Benadryl 50 mg

80-90% of the "migraines" get better with this non-narcotic cocktail.

This is what I use though I swap zofran for compazine. We actually have a pathway for it, so you just check the boxes and it speeds things along. Of course, I probably see fewer drug seekers than most of you.

And I agree, narcotics for headaches is not a good idea anyway.

You guys are obviously missing my tongue-in-cheek humor. Most drug seekers won't be returning much if they keep getting LP'd (no, I'm not advocating it... was only making a joke).

You know, when that whiny teenager comes in and is clearly drama, I do break out the fat boy long LP needle and show it to them. Usually, just opening it up and saying 'well we'll try some fluids and toradol, but if that doesn't work, we may need to do a spinal.' Then I leave them to think about it. They tend to get better quickly.

 

[WilcoWorld]

I use the same cocktail as GV and it's rare that a HA doesn't respond well. If they still complain of enough pain to warrant more meds (ie narcotics) they get offered the needle - if they refuse they get dc'd, if they accept an LP then I figure they deserve the drugs (it makes the tap easier too).

 

[Apollyon]

I use the same cocktail as GV and it's rare that a HA doesn't respond well. If they still complain of enough pain to warrant more meds (ie narcotics) they get offered the needle - if they refuse they get dc'd, if they accept an LP then I figure they deserve the drugs (it makes the tap easier too).

Again, that rebound headache is a buzzkill.

 

[southerndoc]

Again, that rebound headache is a buzzkill.

So is a post-LP headache.

 

[EM2BE]

I've also seen IV Mag added to the mix.

 

[GeneralVeers]

I get so frustrated with a few of my partners at work.

Yesterday a migraine lady came in, she's there monthly for a migraine headache. My partner (a notorious patient-pleasing, drug-giver) picks up the chart, and immediately orders Dilaudid 2 mg IVP and Phenergan 25 mg IVP.

I've asked him before why he practices medicine like that, and his answer is: "I don't want to argue with people, I just want no stress and to go home to my kids".

 

[Rendar5]

Since being taught by headache fellows in med school that there's no role for narcotics with headache patients, I try to steer clear of them.

The only times I've gone to narcotics with headaches are when I'm doing it in consultation with the pt's personal neurologist (believe it or not, this happened to me once) or with an obvious status migraine that I'm having difficulty terminating . IV Compazine +/- NSAIDs is my usual cocktail.

Stitch: how's your luck with Zofran? sometimes my hospital's out of IV compazine, and I just can't seem to get the same effect out of PO compazine or IV reglan, and the studies i've seen on IV reglan seem to support the "meh it's better than nothing" result I get. I've never tried Zofran in that situation and don't know the lit on it.

 

[njac]

I get so frustrated with a few of my partners at work.

Yesterday a migraine lady came in, she's there monthly for a migraine headache. My partner (a notorious patient-pleasing, drug-giver) picks up the chart, and immediately orders Dilaudid 2 mg IVP and Phenergan 25 mg IVP.

I've asked him before why he practices medicine like that, and his answer is: "I don't want to argue with people, I just want no stress and to go home to my kids".

I think I'm more surprised by the Phenergan IVP - that would get you tarred and feathered here!

 

[Stitch]

Stitch: how's your luck with Zofran? sometimes my hospital's out of IV compazine, and I just can't seem to get the same effect out of PO compazine or IV reglan, and the studies i've seen on IV reglan seem to support the "meh it's better than nothing" result I get. I've never tried Zofran in that situation and don't know the lit on it.

In terms of antiemetics ondansetron seems to work fine. I play it up as a wonder drug to add some placebo effect though. I don't know that there's much literature on it, but more my reluctance to use compazine in people under 18 years due to the risk of dystonic reactions. It's still a choice on our pathway, as is metoclopramide. My feeling is that it doesn't much matter which you choose with these patients, as long as you're putting them to sleep and doing some sort of NSAID. Then it's just a waiting game.

 

[Rendar5]

In terms of antiemetics ondansetron seems to work fine. I play it up as a wonder drug to add some placebo effect though. I don't know that there's much literature on it, but more my reluctance to use compazine in people under 18 years due to the risk of dystonic reactions. It's still a choice on our pathway, as is metoclopramide. My feeling is that it doesn't much matter which you choose with these patients, as long as you're putting them to sleep and doing some sort of NSAID. Then it's just a waiting game.

But akithisia's so much fun!

 

[n2b8me]

 

[NateintheED]

In terms of antiemetics ondansetron seems to work fine. I play it up as a wonder drug to add some placebo effect though. I don't know that there's much literature on it, but more my reluctance to use compazine in people under 18 years due to the risk of dystonic reactions. It's still a choice on our pathway, as is metoclopramide. My feeling is that it doesn't much matter which you choose with these patients, as long as you're putting them to sleep and doing some sort of NSAID. Then it's just a waiting game.

I'm also a fan of compazine +/- toradol for headaches/migraines. You can very easily prophylax for dystonia by adding 25-50mg of benadryl to your "cocktail". Plus it helps knock them out. I can count on one hand the number of dystonics I've had in the last 4 years doing it this way. My philosophy: break the headache with the compazine/tordadol, knock them out and send them home to sleep it off the rest of the way.

Actually had a pt about a year ago come in with a laminated letter from her neurologist saying that she would be in the ED several times a month for migraines and would require 40-50mg of IV morphine! Well, that doc had left (high-turnover here) and the new guy was actually trying to get her off narcs. Once she figured out she wasn't going to get her fix, she left with basically no treatment, but no longer needing her sunglasses and generally looking better. Haven't seen her since.

 

[WerdSalid]

One downside to the IV cocktails is the burden on the RN staff of initiating IV placement vs administering an IM injection. My main roadblock is that most, if not all, of our migraneurs have compazine, reglan, toradol, etc listed as an allergy. The funny thing is most just have "NSAIDS" listed. I'd love to call their bluff and administer these meds anyways and just monitor for adverse reactions but should they have a true allergy I would have no medico-legal leg to stand on.

 

[deleted65604]

I try to not give narcotics for migraines. But, sometimes, you learn your lesson after a patient tells you up front that they want narcotics. After 3 hours of milking it along with every non-narcotic pain medicine you can think of, you end up giving in anyway.

Sometimes there is a time to stand and fight, and sometimes the better part of valor is to just get them the heck out of the ER.

 

[GeneralVeers]

Sometimes there is a time to stand and fight, and sometimes the better part of valor is to just get them the heck out of the ER.

There's something to be said for making them wait. If they have to wait 3-4 hours before they finally get their fix, they may think twice about coming back to your ED. After all time is important to these very busy people. They need to make a living by selling Percs.

 

[xaelia]

We don't have Compazine here, so we typically give the IV Benadryl + IV Reglan + IVF for migraine sounding things, I've had occasional success with PO Valium + PO Motrin for obvious tension/musculoskeletal headaches. We actually surprisingly don't have any daily flyers for headaches that I know of. Our frequent flyers seem to be psych, alcohol abuse, or anxiety-chest pain.

I only use ketorolac for patients who aren't tolerating PO.

I have had one patient come in with tons of papers from her neurologist that stated she typically gets 6-8mg of Dilaudid for her headaches. I didn't have the guts to give her all 8mg IV at once, and the nurses still thought I was crazy when I ordered 4mg q15" x2. Worked, kept breathing.

 

[GeneralVeers]

I have had one patient come in with tons of papers from her neurologist that stated she typically gets 6-8mg of Dilaudid for her headaches. I didn't have the guts to give her all 8mg IV at once, and the nurses still thought I was crazy when I ordered 4mg q15" x2. Worked, kept breathing.

Of course it "worked". With 8 mg of Dilaudid, your bloody arm could be cut off and you probably wouldn't care.

That's why so many doctors give it, because it's easy and gets the patient out of the department. It's still very bad medicine.

 

[Aloha Kid]

Our department really cracked down on migrainers. It was a group concensus. We started picking out the frequent fliers. When all agree on a treatment plan in addition to talking with their primary doctors, the migrainers DONT COME BACK. It's awesome.

Don't forget occipital nerve blocks. There's something to be said about just blocking sensation to someones scalp.

Now if our group could just figure something out for our sicklers!!

 

[Katydid]

There's something to be said for making them wait. If they have to wait 3-4 hours before they finally get their fix, they may think twice about coming back to your ED. After all time is important to these very busy people. They need to make a living by selling Percs.

I guess I'm just one of those people who doesn't get the addiction to painkillers.

Mostly because I hate the effects they have on me. And because morphine makes me break out in hives. Vicodin gives me nasty nightmares. Demerol puts my internal monologue on external speaker.

Anyway, the one trip to the ER with a nasty migraine, well, I got sent there because I couldn't feel the right side of my face, and my right hand wasn't responding too well, either. The urgent care doctor was concerned that I might be having a stroke.

By the time I got to the ER? I wouldn't have cared if they'd done an LP. Seriously. I didn't care what the hell they'd do to me, as long as it would make it all stop HURTING. If they'd wanted to take me out back and shoot me to put me out of my misery? I probably would have let them.

So, what do they get out of addiction to painkillers? I mean, I see them all the time, delivering for the pharmacy, and I still don't get it. Most of the time, our resident pillheads just seem out of it. They don't have a clue what the hell is going on around them.

And P.S., that was the one time I went to urgent care for a migraine, too. Most of the time? I go lay down with an ice pack on my forehead, take a couple of Excedrin Migraine, and hope that the pain stops or I die, one or the other. I can usually catch them before the pain really sets in, and that means that while I'm fuzzy-headed afterwards (I feel like my head is stuffed full of cotton, not a good feeling, I call it "headache hangover"), at least I'm not in pain. I don't ever want to have them so frequently or so badly that I think the ER is the best thing for me, to be honest.

 

[GeneralVeers]

I guess I'm just one of those people who doesn't get the addiction to painkillers.

Mostly because I hate the effects they have on me. And because morphine makes me break out in hives. Vicodin gives me nasty nightmares. Demerol puts my internal monologue on external speaker.

Anyway, the one trip to the ER with a nasty migraine, well, I got sent there because I couldn't feel the right side of my face, and my right hand wasn't responding too well, either. The urgent care doctor was concerned that I might be having a stroke.

By the time I got to the ER? I wouldn't have cared if they'd done an LP. Seriously. I didn't care what the hell they'd do to me, as long as it would make it all stop HURTING. If they'd wanted to take me out back and shoot me to put me out of my misery? I probably would have let them.

So, what do they get out of addiction to painkillers? I mean, I see them all the time, delivering for the pharmacy, and I still don't get it. Most of the time, our resident pillheads just seem out of it. They don't have a clue what the hell is going on around them.

And P.S., that was the one time I went to urgent care for a migraine, too. Most of the time? I go lay down with an ice pack on my forehead, take a couple of Excedrin Migraine, and hope that the pain stops or I die, one or the other. I can usually catch them before the pain really sets in, and that means that while I'm fuzzy-headed afterwards (I feel like my head is stuffed full of cotton, not a good feeling, I call it "headache hangover"), at least I'm not in pain. I don't ever want to have them so frequently or so badly that I think the ER is the best thing for me, to be honest.

I guess I don't understand your question or rhetorical argument.

 

[Flopotomist]

Does anybody incorporate a triptan into their approach to patients with migraines in the ED setting?

 

[Rendar5]

Does anybody incorporate a triptan into their approach to patients with migraines in the ED setting?

Only when they have a neurologist I'm talking to. Probably because I dont' have much experience with this and the majority of the time compazine +/- NSAID does the trick.

 

[alphaholic06]

Only when they have a neurologist I'm talking to. Probably because I dont' have much experience with this and the majority of the time compazine +/- NSAID does the trick.

Would substituting phenergan for compazine be as effective?

 

[Katydid]

I guess I don't understand your question or rhetorical argument.

I'm seriously wondering WTF they get out of the whole ER experience.

I don't get it. The painkillers just make you stupid and out of it. I see it every single day with the people we have who are on three different narcotics (at least). I don't understand the attraction of this particular kind of addiction.

And, what I should have added? I can't say that I blame y'all for having protocols that mean that frequent fliers with "migraines" get CT'd and LP'd. If you're willing to wait for four, five, six hours, go through a CT AND an LP? You've got to be in some serious pain and have something wrong with you if you're not just whining that you need dilaudid.

 

[southerndoc]

We don't have policies to CT and LP people with migraines. The problem is a lot of people with "migraines" have never had full workups (CT, LP, MRI), so how do you not know their "migraine" isn't a subarachnoid hemorrhage?

 

[Rendar5]

I'm seriously wondering WTF they get out of the whole ER experience.

I don't get it. The painkillers just make you stupid and out of it. I see it every single day with the people we have who are on three different narcotics (at least). I don't understand the attraction of this particular kind of addiction.

And, what I should have added? I can't say that I blame y'all for having protocols that mean that frequent fliers with "migraines" get CT'd and LP'd. If you're willing to wait for four, five, six hours, go through a CT AND an LP? You've got to be in some serious pain and have something wrong with you if you're not just whining that you need dilaudid.

They get euphoria from it (as opposed to dysphoria which is what you prolly got), or they avoid withdrawal if they're seeking scripts. Or they get money from selling their scripts.

I will say that euphoria can be pretty powerful motivation. I couldn't wait to get my second wisdom tooth pulled because I knew I was gonna get valium IV. I didn't remember anythign except feeling great after the first tooth was pulled. Imagine being excited about surgery because you're gonna get a drug?

 

[ispic]

We don't have policies to CT and LP people with migraines. The problem is a lot of people with "migraines" have never had full workups (CT, LP, MRI), so how do you not know their "migraine" isn't a subarachnoid hemorrhage?

Hi,

H&P - If they have a hx of migraines, and this is their typical exacerbation, then I do the usual drugs (toradol, compazine, benadryl and 1L NS). This takes up the first hour, afterwards, I go for for the 'ol 500mg caffeine in a bag...this will take the second hour. If its a new HA, any new PE findings, family hx of aneurysmal dz/CVA's or something on the hx that points to this being a different HA, then I offer the CT/LP early and strongly encourage them to have both done. One of my attendings told me that "HA from blood is not relieved by medications". Although that might stretch things a bit, If the chronic migraner feels better after the interventions, then...vaya con dios...EB medicine had a decent article on this a few year's back. If anyone wants it, please PM me (I don't think I can post it up on SDN - EULA?)

 

[Rendar5]

Would substituting phenergan for compazine be as effective?

I honestly don't know. I haven't found anything even close to IV compazine (~90% on 20 pt's, some without nausea and without concominant painkillers), including IV reglan and that hits the same neurotransmitters. I doubt they even know why these anti-dopaminergics are effective (and apparently zofran is too and it's not anti-dopaminergic) so I can't theoretically even comment on whether phenergan would be useful.

 

[xaelia]

"HA from blood is not relieved by medications

 

[Interpolfanclub]

Ditto.

 

[Apollyon]

One of my attendings told me that "HA from blood is not relieved by medications".

Saw it as an intern - Toradol for headache, ordered the CT - and subarachnoid blood. Pt had gotten COMPLETE relief. Attending nearly **** a brick - said the same thing - "not blood if pt gets relief from meds". He then wondered how many damn bleeds he'd missed due to symptomatic treatment.

 

[Rendar5]

Saw it as an intern - Toradol for headache, ordered the CT - and subarachnoid blood. Pt had gotten COMPLETE relief. Attending nearly **** a brick - said the same thing - "not blood if pt gets relief from meds". He then wondered how many damn bleeds he'd missed due to symptomatic treatment.

Saw it as a med student in an M&M. Pt got narcotics, got pain relief, had normal CT. But not his typical headache. Was d/c'd with thought that pain relief = no blood. Came back slightly altered a couple hours later and had a Kool-Aid tap..

 

[Arcan57]

I honestly don't know. I haven't found anything even close to IV compazine (~90% on 20 pt's, some without nausea and without concominant painkillers), including IV reglan and that hits the same neurotransmitters. I doubt they even know why these anti-dopaminergics are effective (and apparently zofran is too and it's not anti-dopaminergic) so I can't theoretically even comment on whether phenergan would be useful.

There was an article in Annals looking at IV reglan 20mg vs. compazine 10mg and showed they were pretty equivalent. 10mg of reglan seems to be underdosing if you're treating migraines. Although in that study the incidence of akisthesia equaled that of compazine.

And headaches are just like chest pain, just because it went away with meds doesn't mean its not serious.

 

[Rendar5]

There was an article in Annals looking at IV reglan 20mg vs. compazine 10mg and showed they were pretty equivalent. 10mg of reglan seems to be underdosing if your treating migraines. Although in that study the incidence of akisthesia equaled that of compazine.

And headaches are just like chest pain, just because it went away with meds doesn't mean its not serious.

ah thanks, that probably explains why my reglan results are so crappy.

 

[Katydid]

They get euphoria from it (as opposed to dysphoria which is what you prolly got), or they avoid withdrawal if they're seeking scripts. Or they get money from selling their scripts.

I will say that euphoria can be pretty powerful motivation. I couldn't wait to get my second wisdom tooth pulled because I knew I was gonna get valium IV. I didn't remember anythign except feeling great after the first tooth was pulled. Imagine being excited about surgery because you're gonna get a drug?

Wow.....that's some kind of messed up, right there.

Yeah, there was no euphoria. There was relief when the pain finally ended, but no euphoria. But then, in my personal experience, a migraine is the kind of headache that you start off thinking you're gonna die, progress to hoping you're gonna die, and end up actively praying for death to release you from the pain.

I wouldn't be surprised if some of our pillhead regulars at the pharmacy are selling their scripts. Not in the least. Some of them are pretty skeezy to begin with, and they're the reason I carry pepper spray.

Last week? I had a pillhead who wasn't going to let me leave until she got her refill that the doctor denied her. That was all KINDS of fun.

It must really suck, though, to be so addicted, that you'd sit at the ER for hours on end, just to get pain pills.

 

[Dwindlin]

It must really suck, though, to be so addicted, that you'd sit at the ER for hours on end, just to get pain pills.

May be a gross over generalization but I doubt they have anything better to do.