Frequent Flyers with Migraines

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Katydid said:
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.
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How is that a problem? We just have security escort the disgruntled pillheads out. If they cause any problems or linger around the property we call PD.
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GeneralVeers said:
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.
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I am familiar with the Reglan vs. Compazine study noted above, but could someone point me towards the evidence on the steroids? At my institution I haven't seen anyone giving either Decadron or SoluMedrol for migraine, and I am curious.

Also how do people deal with the Toradol in pregnancy issue? I want to just give everyone this cocktail up front, but early in residency got upbraided for giving it to someone prior to a pregnancy test. This can seriously delay the treatment plan. Do you think it is reasonable to just ask the pt "could you be pregnant right now? Because I'd like to give you a medication that may not be safe in pregnancy" and give the cocktail as long as they say no, despite the known unreliability of patients on such issues?
 
quinsy said:
I am familiar with the Reglan vs. Compazine study noted above, but could someone point me towards the evidence on the steroids? At my institution I haven't seen anyone giving either Decadron or SoluMedrol for migraine, and I am curious.

Also how do people deal with the Toradol in pregnancy issue? I want to just give everyone this cocktail up front, but early in residency got upbraided for giving it to someone prior to a pregnancy test. This can seriously delay the treatment plan. Do you think it is reasonable to just ask the pt "could you be pregnant right now? Because I'd like to give you a medication that may not be safe in pregnancy" and give the cocktail as long as they say no, despite the known unreliability of patients on such issues?
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I avoid the Toradol at first. 20 of Reglan or 10 of Compazine with 50 of Benadryl and 10 of Decadron is enough to start to see if you get relief. That's more than enough time for a Upreg. There was a study in Philadelphia, in 2003 I think, of 705 consecutive women who stated they couldn't be pregnant. 35 were. Patient perception is worth nearly nil.

If you give Toradol in the 2nd or 3rd trimester, you could make the patient miscarry (I tell them outright that, if they are pregnant, they will).

I don't know what "seriously delay" means for your treatment plan.
 
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I have recently become a fan of using caffiene drips for the people who give a classic migraine story after being reassured by one of our neurologists that it's always worth a try.

And I've never seen anyone list caffiene as an allergy. The downside is it's a lot slower than an IM shot.
 
Apollyon said:
There was a study in Philadelphia, in 2003 I think, of 705 consecutive women who stated they couldn't be pregnant. 35 were. Patient perception is worth nearly nil.
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I looked for that just now and this was all I could find:

http://www.ncbi.nlm.nih.gov/pubmed/16794101

Emerg Med J. 2006 Jul;23(7):554-7.
Patient self assessment of pregnancy status in the emergency department.
Strote J, Chen G.

Division of Emergency Medicine, University of Washington Medical Center, Seattle, WA 98122, USA. [email protected]
Abstract
OBJECTIVES: Pregnancy tests are often performed routinely for female emergency department (ED) patients of reproductive age. One major reason is a perception that patients are unreliable in predicting their own pregnancy status. We hypothesised that patients could reliably predict that they were not pregnant. METHODS: The study used a prospective cohort design, in an urban academic ED, from January 19 to May 19, 2004. All patients for whom a pregnancy test was ordered were asked about their sexual history as well as two additional questions: "Do you think you might be pregnant?" and "Is there any chance you could be pregnant?" Patients with already documented pregnancies were excluded. RESULTS: A total of 474 patients had pregnancy tests performed that met inclusion criteria. Eleven (2.3%) tests were positive. Among patients who answered no to both questions (337), one test (0.3%) was positive (negative predictive value (NPV) 99.7%, likelihood ratio (LR) 0.13 (95% CI, 0.02 to 0.82)). The other historical factor with a high NPV (100%) was not being sexually active (LR not calculable). All pregnancies occurred in patients with gastrointestinal or genitourinary as the chief complaint: this comprised only 56% of the presentations for which tests were ordered. CONCLUSION: Sexual history and self assessment can be used as a highly effective predictor of a patient not being pregnant. Given the risks of missed pregnancy in the ED, and low monetary and time cost of pregnancy tests, frequent testing is still recommended in most instances.

PMID: 16794101 [PubMed - indexed for MEDLINE]PMCID: PMC2579552
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quinsy said:
I am familiar with the Reglan vs. Compazine study noted above, but could someone point me towards the evidence on the steroids? At my institution I haven't seen anyone giving either Decadron or SoluMedrol for migraine, and I am curious.
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Steroids in migraine are only supported for prevention of recurrence - not to break the presenting cephalgia: Friedman BW et al. Randomized trial of IV dexamethasone for acute migraine in the emergency department. Neurology 2007 Nov 27; 69:2038.

Also - I check pregnancy on almost every woman that isn't premenarchal or post-menopausal. Yes it slows things down, but that's better than possibly being responsible for birth defects.
 
Katydid said:
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.
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Not nearly as bad as having someone who took an oath to HELP you label you as a drug seeker because you have reached the end of the line with all migraine treatments, and just want to be out of goddamn pain for a few hours.
 
vwgirl said:
Not nearly as bad as having someone who took an oath to HELP you label you as a drug seeker because you have reached the end of the line with all migraine treatments, and just want to be out of goddamn pain for a few hours.
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It doesn't require opiates or pain pills to relieve migraine headaches, nor does it require bumping 3 year old threads to respond to people who may no longer even be there.
 
deuist said:
I will occasionally give opioids for migraines, but that's after reglan, benadryl, toradol, and sumatriptan have failed to do the trick.
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I still generally try IV Keppra or IV Depakote, IV solumedrol, and fioricet (w/ the caffeine effect) before opiates
 
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vwgirl said:
Not nearly as bad as having someone who took an oath to HELP you label you as a drug seeker because you have reached the end of the line with all migraine treatments, and just want to be out of goddamn pain for a few hours.
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1) Pain, by itself, is not a medical emergency.

2) We took an oath to help people; sometimes refusing to give them the medication they are demanding is the most helpful thing we can do.

3) Our job is to rule out the life-threatening conditions. By the time you have reached the end of all migraine treatments, you've been seen by enough specialists and enough time has gone by that we can say "as emergency providers we have nothing to add to the body of medical knowledge in your case. Your condition is not a threat to life/limb/eyesight; you need to see your primary care physician/neurologist."
 
NERDY said:
When I suggested Toradol IV/IM to a specific attending for migraines, he/she said I better be 100% sure that patient did not have a SAH. I don't really want to get CTs for every migraine pt. Any thoughts? Thanks.
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Sure. Your attending is an idiot. You cannot be 100% sure of anything in medicine. There is a point beyond which more testing does harm (the test threshold). I'm more worried about missing an SAH period than the insignificant-to-imaginary increase in bleeding from NSAIDs, so if there are historical features suggesting SAH the. I work it up, otherwise I treat it as I normally would. (I generally do droperidol as first line though.)
 
vwgirl said:
Not nearly as bad as having someone who took an oath to HELP you label you as a drug seeker because you have reached the end of the line with all migraine treatments, and just want to be out of goddamn pain for a few hours.
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If you're allergic to Toradol, NSAIDS, Compazine, Droperidol, Benadryl and Reglan, you are a drug-seeking loser with 99% specificity.
 
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NERDY said:
When I suggested Toradol IV/IM to a specific attending for migraines, he/she said I better be 100% sure that patient did not have a SAH. I don't really want to get CTs for every migraine pt. Any thoughts? Thanks.
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I second the vote for "idiot". I had an attending like this is residency. D-dimers and serum lactates for everybody with him/her. Paralyzed the department.
 
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pseudoknot said:
Sure. Your attending is an idiot. You cannot be 100% sure of anything in medicine. There is a point beyond which more testing does harm (the test threshold). I'm more worried about missing an SAH period than the insignificant-to-imaginary increase in bleeding from NSAIDs, so if there are historical features suggesting SAH the. I work it up, otherwise I treat it as I normally would. (I generally do droperidol as first line though.)
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not sure if we have droperidol at my shop, will have to ask.
 
I once took a presentation from an off service resident who described a migraine, so I recommended a migraine cocktail that included toradol. When I got around to seeing the patient I thought, "Oh crap, this is a bleed!"

It was, and the patient did fine.

Not long after I got transferred a SAH who had gotten toradol - she did fine as well.

n=2
 
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I unfortunately have asked multiple times and my pharmacy seems unable/unwilling to get any :(
 
Rendar5 said:
I unfortunately have asked multiple times and my pharmacy seems unable/unwilling to get any :(
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It has been on shortage at some points.

Have you tried to obtain it immediately, or have you approached going through the P&T committee route?

At my current hospital droperidol is non formulary. We keep zero on hand. Apparently there was previously a policy requiring a baseline (or once it kicked in) EKG, and compliance to this policy was quite low, so the drug was taken away.

I don't agree with said policy, nor was I there when this went down, so I'm not sure how many warnings there were. But the lesson is if your hospital has stupid policies, either fight them the official way through committees, or adhere to them before useful options get removed by the carpet dwellers.
 
WilcoWorld said:
Definitely ask. It's the closest thing we have to a miracle drug.
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I'm not a big fan of droperidol. There are people at my shop who love it and swear by it (and yes, I've used it on people and I admit it does work)... but some of the patients love the loopy feeling they get while taking it. So we've started to see some droperidol seekers.

If it's not one drug it's another.
 
Doctor Bob said:
I'm not a big fan of droperidol. There are people at my shop who love it and swear by it (and yes, I've used it on people and I admit it does work)... but some of the patients love the loopy feeling they get while taking it. So we've started to see some droperidol seekers.

If it's not one drug it's another.
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Or are they "seeking droperidol" because it makes the headache go away?

Droperidol doesn't seem to show up anywhere on the lists where people report abusing anything and everything under the sun.

See:

http://www.erowid.org/experiences/exp_list.shtml#I

and

http://forum.opiophile.org


Droperidol doesn't seem to come up at all.
 
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emedpa said:
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....
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Performing LP's in patients with recurrent H/A's with recent negative w/u and without a change in ha syxs is malpractice, in my opinion.

LP's are not a harmless test.
 
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michaelrack said:
Performing LP's in patients with recurrent H/A's with recent negative w/u and without a change in ha syxs is malpractice, in my opinion.

LP's are not a harmless test.
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that was several years ago and that residency program no longer exists as the hospital closed due to hurricaine katrina...
 
michaelrack said:
Performing LP's in patients with recurrent H/A's with recent negative w/u and without a change in ha syxs is malpractice, in my opinion.

LP's are not a harmless test.
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I suppose if they could prove the LP was unnecessary and there were damages, then yes. Certainly, an unnecessary test is unethical, especially if it's punitive to discourage frequent ED visits, or just for resident education with no benefit to the patient. If it was just needle-in, needle-out with no complication such as a post-dural puncture headache, bleed or infection then I think it would be tough to prove true malpractice in court (must prove duty, breach of duty, injury, and damages). Of course the doc would surely argue that a small percentage of subarachnoid hemorrhages can be missed on CT and that the LP was needed, or that there was a concern for meningitis, etc. LPs are not harmless, but the rate of complications other than post dural puncture headache is very low.

There's a whole lot more of successful cases of malpractice over catastrophic missed head bleeds and meningitis from LPs not done, compared to successful suits over LPs that were unnecessary, that had complications. Therefore, tons of unnecessary tests are done as defensive medicine. We need real tort reform.
 
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I must be in the idiot crowd. I just don't give Toradol for headaches if bleed is anywhere on my differential. I have a hard time giving anything that's inhibiting platelet function to a potential bleed, no matter how unlikely. Think of it this way... it's an absolute contraindication from the drug company. It's on the little white piece of paper than unfolds into a tarp. The lawyer will squeal with glee when he reads that after you miss (ok, probably not...) the SAH.

I just don't give it.

Yea, these headache patients can be difficult. I think you have to rule out the emergent etiologies somehow. If you want to do that with adequate documentation (typical pattern, frequency, documented chronic headaches, non focal, etc.., great... but if you need to LP these guys, then do it. Offer the LP or the CTA and then document that they refused and were educated on risks. Hell, now that I think about it.. I'd almost like to have a negative CTA Brain on these guys showing that there is no aneurysm with much of the literature supporting the fact that sentinel bleeds (not from aneurysms) are largely benign. Especially, if I were going to send them out unhappy that they didn't get their narcs and still complaining of a 10/10 headache.

I think the danger is that we can get really jaded to these drug seekers and at some point in time, these guys will come in with a true emergency and are the most likely patients for it to be missed. Call it "Cried Wolf" syndrome.

Honestly, I'm guilty of just taking a path of least resistance with some of these guys. It's unfortunately easier to just load them with whatever, and get them out the door making room for granny who stopped speaking and moving her R arm 3 hours ago than spend my time wasting with a drug seeker.

Either way, I use compazine, reglan, benadryl, sumatriptan, might add some narcs... depending on the flavor. O2 for the clusters. The steroids is new to me... I'm not up to date on any literature supporting that but I'd be curious. If it works, I'd try it.
 
I'm surprised that more haven't discussed using Droperidol, likely because of the black box warning? This has been shown to be safe, despite not having great FDA support. I haven't given narcotics for a headache in well over a year. There are so many other great options. Droperidol works amazing. You can also try Zyprexa (scant literature on its use but I have had some success) and another thing that hasn't been mentioned is para spinal cervical spine block. If you google it, you can fine a couple videos. I fine that works best for chronic recurrent headaches, typically posterior headaches but have worked for almost all headaches. In my experience works in 60-70% of patients, and have had a couple people tell me that they have never felt that good after it.
Using narcotics for headaches is a bad idea and just bad medicine. I don't offer it to patients and tell them that it causes a rebound headache and is not a recommended treatment option. The headache patients I have our usually the most appreciative, but you need to set boundaries that narcotics will not be used.
 
From the standpoint of a migraine survivor:
My oldest son, who had just turned 11, started having them. Got him in with a neurologist, who gave us the best advice EVER: take 4 200mg OTC iboprofen, and chug a 12oz can of Dr. Pepper. Snaps them every time. worked for both sons as they were entering pubertry (and they have not had issues since they hit about 17). Works great for me, 99% of the time. I go see my primary for Imatrex (dont remember how to spell it) when that doesn't work but it has been a long time since I have had to do that. (At one point, I was having a migraine at least once a week. I am now down to 2 a year)
 
WerdSalid, Jarabacoa, et al...
"Dirt Bags?"

When did it become so "cool" to treat your fellow human beings like crap?

You are all just a bunch of children, brown-nosers, brown-nosing your way up the ladder to become a**hole doctors.

What gives you the right to "judge" people? Your future customers that pay your salary?

Your like the bitch waitress at xyz restaurant snickering and making fun of customers that don't kiss your ass.

If people come to you with a headache, or a back ache, and you don't want to treat them, then just don't treat them. To talk about them all like they are all sub-human is, well, sub human in itself.

According to you jerks, people that make up a pain story to get dilaudid are lowlife dirtbags. Hey, idiots, guess what -- YOUR community created dilaudid, YOUR community doles out addictive drugs, and then you make fun of them all behind their backs.

I, personally, think you all are the most sub-human of the sub-human. You're all nothing but a bunch of bitchy-teenage girls that snicker and make snide remarks behind average-looking boy's backs.

Jerks.
 
Concerned_citizen said:
WerdSalid, Jarabacoa, et al...
"Dirt Bags?"

When did it become so "cool" to treat your fellow human beings like crap?

You are all just a bunch of children, brown-nosers, brown-nosing your way up the ladder to become a**hole doctors.

What gives you the right to "judge" people? Your future customers that pay your salary?

Your like the bitch waitress at xyz restaurant snickering and making fun of customers that don't kiss your ass.

If people come to you with a headache, or a back ache, and you don't want to treat them, then just don't treat them. To talk about them all like they are all sub-human is, well, sub human in itself.

According to you jerks, people that make up a pain story to get dilaudid are lowlife dirtbags. Hey, idiots, guess what -- YOUR community created dilaudid, YOUR community doles out addictive drugs, and then you make fun of them all behind their backs.

I, personally, think you all are the most sub-human of the sub-human. You're all nothing but a bunch of bitchy-teenage girls that snicker and make snide remarks behind average-looking boy's backs.

Jerks.
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Who goes around posting replies to comments that were made nearly 5 years ago?
 
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Translation: I have little understanding of the practice of medicine and even less reading comprehension. Ok, feeding time is over.
 
BoardingDoc said:
Who goes around posting replies to comments that were made nearly 5 years ago?
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Someone who followed a link on a migraine support forum. Happened a while back when discussing gastroparesis. Thread had to be closed.
 
Concerned_citizen said:
According to you jerks, people that make up a pain story to get dilaudid are lowlife dirtbags. Hey, idiots, guess what -- YOUR community created dilaudid, YOUR community doles out addictive drugs, and then you make fun of them all behind their backs.
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got it, so we're in the wrong to complain about people who illegally make up stories to get dilaudid. Thanks. I didn't realize that. I will now shake their hand fully and ask them if they'd like any other drugs while they're in the ED, and let them know how much I respect them for lying to me to score drugs.
 
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Concerned_citizen said:
WerdSalid, Jarabacoa, et al...
"Dirt Bags?"

When did it become so "cool" to treat your fellow human beings like crap?

You are all just a bunch of children, brown-nosers, brown-nosing your way up the ladder to become a**hole doctors.

What gives you the right to "judge" people? Your future customers that pay your salary?

Your like the bitch waitress at xyz restaurant snickering and making fun of customers that don't kiss your ass.

If people come to you with a headache, or a back ache, and you don't want to treat them, then just don't treat them. To talk about them all like they are all sub-human is, well, sub human in itself.

According to you jerks, people that make up a pain story to get dilaudid are lowlife dirtbags. Hey, idiots, guess what -- YOUR community created dilaudid, YOUR community doles out addictive drugs, and then you make fun of them all behind their backs.

I, personally, think you all are the most sub-human of the sub-human. You're all nothing but a bunch of bitchy-teenage girls that snicker and make snide remarks behind average-looking boy's backs.

Jerks.
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And you think that this is all right? This doesn't strike you as wrong, or immoral? Or are you one of those people? It doesn't matter - you won't be back. Thanks for stopping by!
 
It would actually be entertaining to point out all that is wrong with post #89, but it's probably best for the mods to just close this thread.

I do miss Jarabacoa. Long time gone, that one.
 
That's the weird thing about forums like this. You get used to certain people posting frequently and then they just disappear, and you rarely find out why. It's been years since either of them posted, so I doubt they're even reading. One of Jarabacoas last posts said he was happy at his new job. Maybe he's content enough he doesn't need SDN to vent on anymore. Lol. He was a good poster though. Sometimes it's hard to know if people just left SDN, changed screen names and are still around, died tragically in a hot dog eating contest, or are stuck in a Turkish prison. We can speculate, though.

When in doubt: Turkish prison.
 
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DHE 45 works well too.
 
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IV mag also works well, supposedly better than Reglan (See Sept JEM 2014) and you can obviously give it in pregnancy. In the past I've given pts fluids as a part of my HA treatment, and IV Mg has supplanted that. I've begun leaving the Toradol for my "second round" cocktail.

Part of it setting expectations. This is one of the very few times I ask for a pain number. Whatever it is I tell them success is "breaking the HA" (cutting the number in half), and continuing NSAIDs at home. And I tell them that most go to sleep and wake up feeling like a million bucks. Then they get the meds, pass out, and wake up happy.

I can't recall the last time I gave opiates for HA.
 
I had a migraineur come in a while back who was new to our system, seemed straight forward, no red flags, etc. She had no relief from my typical IVF, Toradol, Reglan cocktail. I mentioned that I would try another medicine, Decadron, that seems to work well for some people. She looked over at her husband and said (I sh:t you not), "Maybe that's the D medicine they gave me at [hospital across town] last time we were there." I replied, "Yeah. Probably that or maybe Decadron, well try that next!"

Then shift changed and I left, never looking back.
 
I just give narcs...

I hate to admit it, but it's true. It's not that I go into it offering narcs, but I don't wait until the post-med reeval to discover that what they really want is narcs. I try to get that motive established from the beginning so we can just get this dirty little transaction over with in a timely manner in my single coverage shop, whose administration has a keen interest in satisfaction scores and los compared to others in our region.

I am actually less likely to give narcs if they "suddenly" discover upon reeval that the medicine that begins with D works, after I already have dc papers ready. Also, if at any point they are rude to staff, call me "sweetie" or impede the care of sick patients then they are out the door.

I can't say it's good medicine, but it allows me too provide good care to the others who need and deserve my time and expertise.
 
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