Headache cocktail....any good?

[amysdad]

Hello cyber collogues. Is anyone else using the Beneadryl-decadron-compazine for HA’s? What is the consensus?

John

---

Members don't see this ad.

 

[GeneralVeers]

Hello cyber collogues. Is anyone else using the Beneadryl-decadron-compazine for HA’s? What is the consensus?

John

I use Toradol-Reglan, or Toradol-Phenergan. They get rid of 80%-90% of headaches in my experience. The literature suggests you can use high dose reglan (up to 80mg!) by itself and it will be effective.

 

[southerndoc]

I use Toradol-Reglan, or Toradol-Phenergan. They get rid of 80%-90% of headaches in my experience. The literature suggests you can use high dose reglan (up to 80mg!) by itself and it will be effective.

I usually draw the line at 40 mg. 10, 10+Benadryl, then try to go with other agents. Occasionally I'll keep on the Reglan path until 40 mg is given.

I saw the article from NYU. I'm surprised they administered up to 80 mg.

We refrain from administering Toradol here in case of subarachnoid hemorrhages.

 

[southerndoc]

Also, DHEA also works great.

 

[12R34Y]

Agreed with NO TORADOL. our staff won't give it ever for headaches just because of the risk of SAH. We use virtually any other pain agent, but no NSAIDs.

Also compazine/reglan/phenergan and benadryl is standard here.

later

 

[SoCuteMD]

Agreed with NO TORADOL. our staff won't give it ever for headaches just because of the risk of SAH. We use virtually any other pain agent, but no NSAIDs.

Also compazine/reglan/phenergan and benadryl is standard here.

later

Funny that you mention that...as a little MS2 (yay!) who hasn't taken pharm yet I hadn't thought of that. A few days ago in the ED a family member of a patient pulled me aside and said, "What can I do for a headache." I thought, "Duh...advil, aleve, excedrin, tylenol" but said, "I'm not really sure, ma'am, since I'm just a student. You can ask the doctor."

 

[bartleby]

If someone has a documented SAH, it would be reasonable to avoid giving a non-selective NSAID to avoid platelet antagonism. This is also reasonable if someone has a story concerning for an SAH and you're doing the CT-LP workup in the ED. I don't think there's any rationale for withholding NSAIDs from someone that you think has a migrane and will be treated as such unless they have an independent contraindication. In non narcotic-seekers, toradol plus reglan/compazine/phenergan (dealer's choice) is a great first line treatment.

 

[kungfufishing]

I've had great luck with compazine alone.

 

[leviathan]

Agreed with NO TORADOL. our staff won't give it ever for headaches just because of the risk of SAH. We use virtually any other pain agent, but no NSAIDs.

Also compazine/reglan/phenergan and benadryl is standard here.

later

Normally I will have no problems giving ASA or other NSAIDs unless there is a reason I suspect an SAH. If a pt. complains of a typical headache that they always get, then I don't worry too much. Otherwise, I'm sure tylenol works wonders. But I am just a lowly EMT, so what do I know? Still, that's my $0.02.

 

[GeneralVeers]

Has Toradol ever been demonstrated to increase bleeding from SAH?

I agree that I would hold it for someone who has the typical "sudden onset worst headache of life" but for the person who says "this is my usual migraine" and I'm not going to scan them, I'll give Toradol.

 

[anonymousEM]

for some compazine alone gives the "gotta get outta here" akethesias....if you think they're sick and want them to stay give benadryl too...I have to admit there were a few pain in the neck "worst headache of my life" drug seekers who I wanted to try it just to see if it'd make them leave AMA, but of course I only thought about it....

 

[ntubebate]

Don't forget that adquate hydration should be given.

ntubebate

 

[DrQuinn]

I used to do one gram of magnesium, 25 of benadryl, and 10 of reglan during residency. worked great. I ordered it at my new job now, and apparently its nursing protocl to put people on a monitor when you give 'em mag, so that's kind of a pain in the butt, so I just give reglan and benadryl. Works great. Probably have a 90% success rate.

Don't forget caffeine in post-LP headaches. I got about an 80% success rate with that alone.

Q

 

[GeneralVeers]

I used to do one gram of magnesium, 25 of benadryl, and 10 of reglan during residency. worked great. I ordered it at my new job now, and apparently its nursing protocl to put people on a monitor when you give 'em mag, so that's kind of a pain in the butt, so I just give reglan and benadryl. Works great. Probably have a 90% success rate.

Don't forget caffeine in post-LP headaches. I got about an 80% success rate with that alone.

Q

How do you give them caffeine? Buy them a cup of coffee?

If you guys have a caffeine IV drip, then hook it up to me right now!

 

[Shodddy18]

How do you give them caffeine? Buy them a cup of coffee?

If you guys have a caffeine IV drip, then hook it up to me right now!

I could seriously use some of that right now!

 

[Apollyon]

How do you give them caffeine? Buy them a cup of coffee?

If you guys have a caffeine IV drip, then hook it up to me right now!

500mg in 1L 0.9% saline, infuse over 1hr.

 

[Shodddy18]

500mg in 1L 0.9% saline, infuse over 1hr.

Sign me up for some of that!!!

I'll just have to settle for my canned starbucks double shot

 

[GeneralVeers]

500mg in 1L 0.9% saline, infuse over 1hr.

Would have been great on my medicine rotation last year. All day naps were the norm.

 

[roja]

I find it odd that there is this percieved caveat of no NSAIDs in headache patients because of the fear of SAH.

Now, if you are in the midst of working up a headache for SAH, then sure, avoid NSAIDS.

However, if you are waiting to make up your mind, seeing if they get better with antiemetics, etc, and then deciding if you think its a SAH you are going down a dangerous and half-cocked pathway.

You should make the decision EARLY (ie prior to treatment) if you are concerned for SAH. If you are, then you need to go down that pathway. If you aren't, then you shouldn't be afraid to add on a NSAID for pain management.

This is similar to sending one troponin but no ASA or betablocker when you don't think its really acs/mi but you want some kind of reassurance... Its an inappropriate and false sense of security. If you think its ACS, then you need to go down that path. If you don't, you shouldn't send the troponin.

That said, if I think no SAH, then the headache protocol I use is IVF, Reglan, Toradol. +/- benadry. Works splendidly. The one thing I don't give is narcotics for headaches.

 

[southerndoc]

Has Toradol ever been demonstrated to increase bleeding from SAH?

I've never read literature directly examining NSAIDs with SAH, but I have seen literature that demonstrates that NSAIDs used preoperatively significantly increases the rates of transfusion, bleeding, etc. One can deduce -- albeit not confirmatively -- that NSAIDs will increase bleeding from aneurysmal causes as well.

More importantly, has anyone demonstrated NSAIDs used in combination with other meds (i.e., metoclopramide, compazine, etc.) is superior to standard treatment alone?

 

[southerndoc]

You should make the decision EARLY (ie prior to treatment) if you are concerned for SAH. If you are, then you need to go down that pathway. If you aren't, then you shouldn't be afraid to add on a NSAID for pain management.

Words definitely worth repeating. A significant number (I've heard, but haven't verified the number is 60%) of patients with subarachnoid hemorrhages will have pain reduction with metoclopramide or similar agents.

 

[kungfufishing]

Ive had a lady with a leaking cerebral aneurysm who had great pain relief with compazine. long and complicated story, but presented with a typical headache at 1 AM,and had multiple visits for same. For some reason got scanned - worked up by another resident/attending - and sent home. Came back at 0830 after I had come on, headache worse, got an LP, entirely pink and never cleared, actually seized 20 seconds after I removed the needle (really not a good feeling)
CTA --> 10mm aneurysm ---> NSG. I dont know if this was the etiology of her headaches over the past 1.5 or so years that she had been visiting.

 

[southerndoc]

I wonder why CTA hasn't replaced LP's yet? In my facility, all positive LP's get a CTA Circle of Willis. From our neurosurgeons, it's actually more sensitive and specific than an MRA.

 

[dhb]

500mg in 1L 0.9% saline, infuse over 1hr.

do you think it's the caffeine or the 1L of saline that does the trick??

 

[GeneralVeers]

I've never read literature directly examining NSAIDs with SAH, but I have seen literature that demonstrates that NSAIDs used preoperatively significantly increases the rates of transfusion, bleeding, etc. One can deduce -- albeit not confirmatively -- that NSAIDs will increase bleeding from aneurysmal causes as well.

More importantly, has anyone demonstrated NSAIDs used in combination with other meds (i.e., metoclopramide, compazine, etc.) is superior to standard treatment alone?

Supposedly the mechanism behind headaches is vasodilation. Theoretically the NSAIDS are supposed to cause some vasoconstriction and relieve the headache.

As has beeen previously mentioned I make the SAH/NOT SAH decision early, and treat accordingly.

 

[12R34Y]

Supposedly the mechanism behind headaches is vasodilation. Theoretically the NSAIDS are supposed to cause some vasoconstriction and relieve the headache.

As has beeen previously mentioned I make the SAH/NOT SAH decision early, and treat accordingly.

I guess the whole point that was make at our last lecture was that up to 25-50% of SAH's are missed on first visit to ED for headache!!! yikes!

so, the natural conclusion is that even though you may not THINK someone is having a SAH it turns out lots of us are wrong lots of times.

This leads to the argument that why would you then give the only pain med that has even the slightest chance of causing WORSENING of that catastrophic condition when you have a myriad of other options that WON'T cause that same chance?

later

 

[bartleby]

That's like saying that once in a while, aortic dissections are only found by accident during a cardiac cath, and that anticoagulation and antiplatelet agents are bad for dissections, so you should heparinize someone who you think is having an MI just in case you're missing a dissection.

Good medicine here is doing what's right so you avoid missing that SAH in the first place, not a CYA maneuver to mitigate your humiliation in an M&M conference gone awry that haunts your nightly in your dreams. Undertreating everybody else with a benign-sounding migrane headache is not the answer. Plus, there's no evidence-based data I'm aware of which shows that a single dose of toradol worsens the clinical outcome even when accidentally given in the case of an SAH/ICH.

Everybody here seems to agree that opioids in migranes are a bad choice, yet NSAIDs are a solid second line med behind an antiemetic in terminating or at least yanking the rug out from underneath a bad headache.

 

[DocWagner]

My big med of choice now is HALDOL, plus minus benadryl. It has worked wonders thus far.
At my hospital there is a HUGE overuse of narcotics both past and present, with some patients showing up weekly for their headaches. This does not work well with me...therefore I use Haldol. And based on some recent studies it has some literature to back up this practice.

Other cocktails include: Toradol and Phenergan, Toradol and Compazine, Reglan and Nubain, Nubain and Phenergan, DHE, Antivert and toradol blah blah

 

[12R34Y]

That's like saying that once in a while, aortic dissections are only found by accident during a cardiac cath, and that anticoagulation and antiplatelet agents are bad for dissections, so you should heparinize someone who you think is having an MI just in case you're missing a dissection.

Good medicine here is doing what's right so you avoid missing that SAH in the first place, not a CYA maneuver to mitigate your humiliation in an M&M conference gone awry that haunts your nightly in your dreams. Undertreating everybody else with a benign-sounding migrane headache is not the answer. Plus, there's no evidence-based data I'm aware of which shows that a single dose of toradol worsens the clinical outcome even when accidentally given in the case of an SAH/ICH.

Everybody here seems to agree that opioids in migranes are a bad choice, yet NSAIDs are a solid second line med behind an antiemetic in terminating or at least yanking the rug out from underneath a bad headache.

I don't think comparing it to aortic dissection is correct at all. You don't miss 25-50% of the time!

Also, how I am I undertreating headaches with fentanyl/dilaudid/caffeine/mag/reglan/compazine etc..??!! Plus, fentanyl/dilaudid don't potentially worsen a SAH. Makes sense to me.

later

 

[bartleby]

You need to do what you're comfortable with, but there's no science behind avoiding a perfectly good class of meds in all comers with a headache.

Narcotics are good for headaches, no doubt...it's also good for giving people with what is essentially a chronic pain problem positive reinforcement for coming to the Emergency Department for treatment instead of taking advantage of their other non-opioid treatment regimens at home. Narcotics should be a treatment used after other modalities are exhausted.

Plus, fentanyl/dilaudid don't potentially worsen a SAH. Makes sense to me.

 

[ntubebate]

Cocktail:
1L NS wide open
Benadryl 25mg
Nubain 5mg
Haldol 2mg

> 90% of patients do well with this combination.

ntubebate

 

[GeneralVeers]

I don't think comparing it to aortic dissection is correct at all. You don't miss 25-50% of the time!

Also, how I am I undertreating headaches with fentanyl/dilaudid/caffeine/mag/reglan/compazine etc..??!! Plus, fentanyl/dilaudid don't potentially worsen a SAH. Makes sense to me.

later

You're missing the intent of previous arguments. If you do a good H&P, within 5 minutes you should have an idea of whether or not you're going to work-up the patient for SAH. If you're going down the SAH pathway, then you're correct, don't give Toradol, ASA, etc. For the 80% of people who aren't getting worked up as SAH, I'll give the toradol.

 

[ERMudPhud]

This thread seems to come up a lot

http://forums.studentdoctor.net/showthread.php?t=292943
http://forums.studentdoctor.net/showthread.php?t=238253
http://forums.studentdoctor.net/showthread.php?t=190493
http://forums.studentdoctor.net/showthread.php?t=121597

For the advocates of Toradol I wonder about the evidence it works. In trials it is all over the map, sometimes no better than placebo, sometimes better than Demerol!

As I said before given the huge placebo effect with migraines I think placebo controlled trials are essential. In that context the best evidence is for compazine, thorazine, and reglan. Placebo controlled evidence is much weaker for Mg, Phenergan, Depakote, Haldol, Toradol. In head to head studies involving compazine and other choices compazine always won. I just saw another recent study showing compazine way better than phenergan

To everyone who is so sure they can decide based on initial workup the likelihood of a SAH I would ask how many subtle SAH's you've seen. I don't mean the catastophic head bleeds that are obtunded. I mean the HA with normal neuro exam and a subsequent SAH. In my case I think its been less than 4 in 9 years and I'm very aggressive about the CT/LP. For many residents the answer would be none. My point is we don't see it enough to really know how good we are at picking it up in the history and physical. You may think that you are aggressive about CT/LPing everyone with any thought of a SAH but the truth and the evidence would indicate that we still miss it. Just look at the Sharon Stone case from a few years ago. How many days was she in the hospital being seen by a variety of specialists before they arrived at the diagnosis.

 

[roja]

I think that in general, we are better at picking them up than we think, more in the sense that we tend to be more conservative and CT/LP people more than even we want to, but do it because we don't want to miss it. Perhaps Stone was suffering from 'Important Person Status'.

We are currently doing a prospective database collection on all LP's done in our institution and are gauging things like indications, suspicion prior to LP, after LP, and diagnosis after results to see if we can get a feel for how good we really our with our clinical suspicion... should be interesting.

 

[GeneralVeers]

To everyone who is so sure they can decide based on initial workup the likelihood of a SAH I would ask how many subtle SAH's you've seen. I don't mean the catastophic head bleeds that are obtunded. I mean the HA with normal neuro exam and a subsequent SAH. In my case I think its been less than 4 in 9 years and I'm very aggressive about the CT/LP. For many residents the answer would be none. My point is we don't see it enough to really know how good we are at picking it up in the history and physical. You may think that you are aggressive about CT/LPing everyone with any thought of a SAH but the truth and the evidence would indicate that we still miss it. Just look at the Sharon Stone case from a few years ago. How many days was she in the hospital being seen by a variety of specialists before they arrived at the diagnosis.

How many of those missed head bleeds are clinically significant, meaning that they require treatment or will get worse if missed? In truth we probably all miss a few, but is the outcome for those patients different?

 

[southerndoc]

How many of those missed head bleeds are clinically significant, meaning that they require treatment or will get worse if missed? In truth we probably all miss a few, but is the outcome for those patients different?

Although it's anecdotal data, I do know of one missed sentinel bleed that died only 1 week later with a massive subarachnoid bleed. Seemed she presented to the ED complaining of pain typical of her migraine headaches, had an MRI/MRA done only a week prior that showed no aneurysms (according to her; was done at an outside facility). The patient had a normal neurologic exam and a negative CT. Because her pain was relieved and this was a "typical headache" for her, it was elected not to pursue this any further. Plus, she had recently had a negative MRA.

She was at a local sporting event observing a family member playing softball when she suddenly complained of an intense, sudden onset headache, fell off the bench, and went unresponsive. Ventilatory support was withdrawn a few days later due to no chance of survival.

Although the SAH you may see in the ED at the time might not be unstable, I would argue that all SAH's and missed bleeds (sentinel bleeds) are clinically significant. It's like the missed PE. It's not the current one that might be the most devastating, but a missed diagnosis is a missed opportunity to prevent sudden, catastrophic brain injury in a fully functioning human being.

 

[GeneralVeers]

Although the SAH you may see in the ED at the time might not be unstable, I would argue that all SAH's and missed bleeds (sentinel bleeds) are clinically significant. It's like the missed PE. It's not the current one that might be the most devastating, but a missed diagnosis is a missed opportunity to prevent sudden, catastrophic brain injury in a fully functioning human being.

I understand your reasoning, but following it through to a logical conclusion, we should scan EVERYONE with a headache, as SAH can present with typical migraine symptoms. I'm not a fan of this type of medicine, however it seems to be becoming more commonplace among my colleagues and superiors as fear of liability increases.

 

[Dimoak]

I'm not an expert, but this sure seems like a slippery slope. I suppose it really does come down to your interpretations of the pt's pain scale and GCS when acessing migraines to determine if the recurrence, effect of meds/therapy, etc. warrent a scan, especially if you suspect bleeding somewhere. As many have said, chances are that if we scan everything, we'll usually never miss something, but then again the price of actually having a scan done may deter many from such a practice. Is anyone aware of any conclusive literature that actually gives evidence-supported concrete numbers on when to scan ASAP and when to send a pt home with some meds and a followup?

 

[GeneralVeers]

I think everyone here has their own algorithm that they follow.

I scan under the following situations:

- Head trauma with LOC, neuro deficit, or significant injury (or any head trauma in old people)
- Sudden onset excruciating headache
- Migraine significantly worse than normal
- New headache in a patient with no migraine history
- Progessively worsening headache over several weeks
- Headache with severe hypertension (>200 SBP)

Treat conservatively for:

- Migraine similar to past
- Headache secondary to nausea/vomiting with evidence of dehydration
- Mild, chronic headache
- Headache, minor head trauma with no LOC (except in old people)
- Hangovers (otherwise I'd have to scan myself several times monthly)

 

[beyond all hope]

I personally like Compazine and Tylenol, +/- Benadryl. IVF helps if its a dehydration HA.

Not a big fan of Toradol in general, but especially for HA (evidence works well for prostaglandin pain such as kidney stones, lots of evidence that it has way more side effects than most analgesics)

That being said, I don't like to get tied up curing headaches. If you don't think they have acute pathology, treat 'em, write up their papers and move on. You don't have to cure headaches in the ED.

You do have catch SAH, meningitis, bleeds, Temp arteritis, glaucoma, etc. (note HCT only catches a few of the dangerous dxs. Still gotta use your brain and do a good Hx/PE.)

Don't wait around for a reeval unless you really think you're missing something. Spend too much time trying to cure a headache and you won't be spending enough time with the people with true emergencies.

 

[drsutter]

First line: 0.9 NS 2 liters bolus with toradol, compazine
Then if not work: solumedrol/decadron and benadryl

 

[Painter1]

dug up this interesting discussion of a couple months ago. one thing no one ever mentioned in acute treatment of migraine was sumatriptan. anyone use sumatriptan 6mg SQ in the er for migraine?

lastly, what do you send these people home with? imitrex, compazine, ibuprofen? also, in someone with frequent migraines would prophylatic meds (e.g nortriptyline, b-blocker etc) ever be appropriate dispo rx from the ER or would u leave that for neurologist?

 

[12R34Y]

I understand your reasoning, but following it through to a logical conclusion, we should scan EVERYONE with a headache, as SAH can present with typical migraine symptoms. I'm not a fan of this type of medicine, however it seems to be becoming more commonplace among my colleagues and superiors as fear of liability increases.

I don't see this statement as meaning you scan every headache. I just wouldn't give toradol for a headache. You are going to miss SAH in a headache presentation now and then. I just choose ( as do our faculty) to not potentially worsen the one that I miss by giving toradol when there are tons of other great options that aren't NSAIDS.

 

[leviathan]

I don't see this statement as meaning you scan every headache. I just wouldn't give toradol for a headache. You are going to miss SAH in a headache presentation now and then. I just choose ( as do our faculty) to not potentially worsen the one that I miss by giving toradol when there are tons of other great options that aren't NSAIDS.

So would you advocate for headaches being an absolute contraindication to taking NSAIDS?

 

[12R34Y]

So would you advocate for headaches being an absolute contraindication to taking NSAIDS?

Nope, I take ibuprofen for my headaches all of the time. But, I don't give other people toradol for headaches. that's just the way I practice. Everyone has to decide on a practice style and it is based on evidence/common-sense/personal experience and who trained you.

for me.......based on the fact that SAH is often missed on intitial presentation and they can present as virtually any headache syndrome. As with most "classic presentation" they occur rarely.

Knowing that toradol produces affects platelet aggregation.

Knowing that there are other treatment modalities available that AREN'T NSAIDS. (numerous in fact).

Based on this it is sound reasoning in my mind for me not to give toradol to headaches.

that's the reasoning............I'll await any wonderful EBM out there that disputes this conclusively and THEN change my practice.

In the meantime...............

to each his own

 

[USAF MD '05]

I usually forget to do this, but I have seen a number of docs give the typical migrainer one Ambien to go home with as getting a good 8 hours of sleep helps reduce rebound HA's. Not sure of the science, and too lazy to look and see if there is some, but can't hurt. Steve

 

[FoughtFyr]

I don't think comparing it to aortic dissection is correct at all. You don't miss 25-50% of the time!

Also, how I am I undertreating headaches with fentanyl/dilaudid/caffeine/mag/reglan/compazine etc..??!! Plus, fentanyl/dilaudid don't potentially worsen a SAH. Makes sense to me.

later

Really?!? What do you think the "miss rate" on aortic dissection is versus the "miss rate" of SAH?

(I've got the aorta paper, I'll find the SAH one and post soon).

- H

 

[Hawkeye Kid]

Supposedly the mechanism behind headaches is vasodilation. Theoretically the NSAIDS are supposed to cause some vasoconstriction and relieve the headache.

Why would toradol cause vasoconstriction (presumably via smooth muscle) but ureteral relaxation (again, presumably through smooth muscle)? I'm a little shaky on my cell/tissue physiology, but this seems strange to me. Are they different types of muscle? Any thoughts???

 

[leviathan]

Nope, I take ibuprofen for my headaches all of the time. But, I don't give other people toradol for headaches. that's just the way I practice. Everyone has to decide on a practice style and it is based on evidence/common-sense/personal experience and who trained you.

Oh, I didn't necessarily mean for personal use; just as an absolute contraindication for patient treatment. I agree with your reasoning that if there are alternatives which are just as effective as toradol and will not cause any potential adverse outcomes, might as well play it safe.

 

[12R34Y]

Really?!? What do you think the "miss rate" on aortic dissection is versus the "miss rate" of SAH?

(I've got the aorta paper, I'll find the SAH one and post soon).

- H

Hey long time no talk foughtfyr! how have you been!?

Anway.......I guess my point about dissection versus headache patient is that most all of the headache patients get sent home and don't get CT heads/LP's. So giving them something that affects platelets and then sending them on their way is my issue.

On the other hand if aortic dissection is on your differential (which it almost always is in chest pain) we almost never send these folks home and are admitted to at least 23 hour obs.

so, while I appreciate the point that we miss both aortic dissections often as well and we still give them ASA if they have chest pain. ASA has great benefit along with some risk. Whereas, toradol has no proven benefit (ie mortality), but has risk.

Curious as to your response.

later