Low dose propofol for migraine

[ditch doctor]

There has been a lot of press about this lately, especially in MedScape and I think there was something about this on emrap, too. Anyone try this? Me and the people from our group were talking about it. Anyone have success stories? Anyone have any protocols/policies? Would you have to do sedation paperwork even though it's at non-anesthetic levels?

DD

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[southerndoc]

I've never heard of this. We have a propofol shortage nationwide right now, so excellent timing.

Of course, lots of patients will now become "allergic" to propofol!

 

[ditch doctor]

I've never heard of this. We have a propofol shortage nationwide right now, so excellent timing.

Of course, lots of patients will now become "allergic" to propofol!

DD: Ms Smith any allergies?

Ms Smith: Yes: toradol, vistaril, compazine, benadryl, reglan, ergot derivatives, morphine and propofol. My throat closes with all of them and they needed to code me. I almost died.

DD: Huh. Any surgeries?

Ms. Smith: Oh yes! Gall bladder, hysterectomy, orif right leg, hernia repair.

DD: Problems with anesthesia?

Ms Smith: None.

 

[Arcan57]

There has been a lot of press about this lately, especially in MedScape and I think there was something about this on emrap, too. Anyone try this? Me and the people from our group were talking about it. Anyone have success stories? Anyone have any protocols/policies? Would you have to do sedation paperwork even though it's at non-anesthetic levels?

DD

We tried to do this with ketamine (not for migraines) and even at sub-disassociative doses the hospital was still requiring the full procedural sedation set-up and monitoring. I don't see any way in hell of getting propofol through P&T for this indication.

 

[dotcb]

So many other effective therapies. Have never felt I needed this.

Have also had little success arguing that small doses of ketamine can be given for pain w/o full sedation paperwork & monitoring.

There has been a lot of press about this lately, especially in MedScape and I think there was something about this on emrap, too. Anyone try this? Me and the people from our group were talking about it. Anyone have success stories? Anyone have any protocols/policies? Would you have to do sedation paperwork even though it's at non-anesthetic levels?

DD

 

[DeadCactus]

Yea, it was on EM:RAP but they emphasized that it was still in the experimental phase and I think they used it only for extremely refractory cases...

 

[Rendar5]

I only briefly looked at the decadron vs. propofol paper that came out. iirc, propofol had a greater relief than decadron. 40% improvmenet vs. 60% improvement. the problem though is that there was a ergot vs. compazine paper a few years ago for migraines that had 60-70% improvement vs. 90+% improvement. so sure it has some benefit but the overall benefit is really no better than well-established meds. So sure, you can use it, for me it's gonna be my 8th line drug. after compazine, droperidol, reglan, toradol, normal saline, fioricet, depakote, and high dose solu-medrol.

 

[Birdstrike]

When you progress along the continuum of analgesia and sedation, eventually you get to conscious sedation, and ultimately general anesthesia. Sure, enough of any narcotic, benzo, sedative, ketamine or propofol and you'll get pain relief. The question is, "Just because you can, should you?"

Propofol, lidocaine drips, ketamine drips, halothane, pentobarbital coma in the ED? In the ED? Now, I'm all for treating pain, but where does it stop?

Surely it's a guaranteed way to A++ patient sat score at the expense of reason, and will be sure to attract patients who will learn to ask for these treatments by name. But realistically, if you're even thinking of going down these roads, you should be consulting a specialist team and moving on to the next patient, in my humble opinion.

 

[EM_Rebuilder]

Really? Propofol for headaches!!

Whats next; using Propofol for a sleep aide... Wait.

 

[tkim]

for me it's gonna be my 8th line drug. after compazine, droperidol, reglan, toradol, normal saline, fioricet, depakote, and high dose solu-medrol.

Can you even get compazine any more? Haven't seen it in 6 months minimum.

 

[Rendar5]

unfortunately not at my current gig since I started 8months ago. I assume someone just stopped producing it at noncrazy prices. hopefully if some schmuck is gray-marketing it, he's losing a ****-ton of money. can't get droperidol either. so i guess then propofol is down to 6th in line lol.

 

[njac]

Can you even get compazine any more? Haven't seen it in 6 months minimum.

We finally have it again, after being out for over a year.

 

[ditch doctor]

When you progress along the continuum of analgesia and sedation, eventually you get to conscious sedation, and ultimately general anesthesia. Sure, enough of any narcotic, benzo, sedative, ketamine or propofol and you'll get pain relief. The question is, "Just because you can, should you?"

Propofol, lidocaine drips, ketamine drips, halothane, pentobarbital coma in the ED? In the ED? Now, I'm all for treating pain, but where does it stop?

Surely it's a guaranteed way to A++ patient sat score at the expense of reason, and will be sure to attract patients who will learn to ask for these treatments by name. But realistically, if you're even thinking of going down these roads, you should be consulting a specialist team and moving on to the next patient, in my humble opinion.

From my understanding of the medscape trial that I read it was very low dose; like 10-20mg boluses, wait ten minutes, do it again until headache gets better. Not a propofol coma. Almost like giving 0.5mg or so of morphine to an adult. I can't see how any adult would get sedated at that dose. It seemed to work. I think comparing this to general anesthesia or a pentobarb coma fails the apples to oranges test.

Also, I'm not implying this as the "go to" drug for migraine. But we all have the person that nothing works for their headache, multiple allergies etc. Resorting to putting them to sleep with a crap ton of vistaril and phenrgan or getting them high on opiods to bounce back tomorrow for their rebound headache just to move the meat makes me feel like a failure. I like to find stuff that truly helps. I think we get too cynical and assume everyone that fails compazine therapy is really there for some "happy", when they really just want relief.

Case in point, I recently started using cervical IM injections of bupivicaine for all pain from the neck up a few months ago; got it from emrap. If you don't know about this you should look it up. Just last week I had that patient that everyone rolls their eyes and says, "oh, *&%$, Ms So-in-so is here for her dope". I enter the room: lights out, wet rag over eyes, drag a neuro exam out of them. I injected her and 10 minutes later she was smiling. She actually thanked me because usually she gets phenergan and demerol and she hates the way it makes her feel. True story.

As far as calling in a specialist, propofol is a very safe drug (MJ jokes aside) and if this is effective treatment, $5 of propofol and 1 hour of my time would do more to help this patient and healthcare in general than consulting a specialist, don't you think? It would also save an owing your internist a favor for admitting a headache for pain control that s/he probably will get refused payment.

I wonder what is so magical about propofol that makes everyone so reticent to try this. All the other "go to" drugs have arguably much worse side effect profiles. I wonder if people would be so reticent to try 0.1mg of Versed or 1mg of etomidate or 5mg of methohexital every 10 minutes. Probably not.

 

[Hamhock]

I wonder what is so magical about propofol that makes everyone so reticent to try this. All the other "go to" drugs have arguably much worse side effect profiles. I wonder if people would be so reticent to try 0.1mg of Versed or 1mg of etomidate or 5mg of methohexital every 10 minutes. Probably not.

I would be reluctant to stand at the bedside and push normal saline every ten minutes.

I only do this for critical care (ie repeated valium pushes for severe alcohol withdraw)...and I bill for critical care. I doubt you can bill for critical care on a headache patient.

Otherwise, I'd be on board.

HH

 

[Birdstrike]

From my understanding of the medscape trial that I read it was very low dose; like 10-20mg boluses, wait ten minutes, do it again until headache gets better. Not a propofol coma. Almost like giving 0.5mg or so of morphine to an adult. I can't see how any adult would get sedated at that dose. It seemed to work. I think comparing this to general anesthesia or a pentobarb coma fails the apples to oranges test.

Also, I'm not implying this as the "go to" drug for migraine. But we all have the person that nothing works for their headache, multiple allergies etc. Resorting to putting them to sleep with a crap ton of vistaril and phenrgan or getting them high on opiods to bounce back tomorrow for their rebound headache just to move the meat makes me feel like a failure. I like to find stuff that truly helps. I think we get too cynical and assume everyone that fails compazine therapy is really there for some "happy", when they really just want relief.

Case in point, I recently started using cervical IM injections of bupivicaine for all pain from the neck up a few months ago; got it from emrap. If you don't know about this you should look it up. Just last week I had that patient that everyone rolls their eyes and says, "oh, *&%$, Ms So-in-so is here for her dope". I enter the room: lights out, wet rag over eyes, drag a neuro exam out of them. I injected her and 10 minutes later she was smiling. She actually thanked me because usually she gets phenergan and demerol and she hates the way it makes her feel. True story.

As far as calling in a specialist, propofol is a very safe drug (MJ jokes aside) and if this is effective treatment, $5 of propofol and 1 hour of my time would do more to help this patient and healthcare in general than consulting a specialist, don't you think? It would also save an owing your internist a favor for admitting a headache for pain control that s/he probably will get refused payment.

I wonder what is so magical about propofol that makes everyone so reticent to try this. All the other "go to" drugs have arguably much worse side effect profiles. I wonder if people would be so reticent to try 0.1mg of Versed or 1mg of etomidate or 5mg of methohexital every 10 minutes. Probably not.

What you are talking about is a trigger point injection. Rheumatology, Pain, Neuro, FP all do these. It's valid thing to do for muscle pain, trigger points, muscle spasm, myofascial headaches, headaches which are referred from the neck, etc. They can work. Occipital nerve blocks are easy and can be done too, for occipital headaches/neuralgia, etc. Just be remember: in a thin person's neck, you can get to the epidural or intrathecal space with a 27 gauge 1.5 inch needle and could end up with a high spinal block, if not careful, i.e. you're intubating. Also, in the upper cervical area, the foramen magnum is reachable with the same standard needle. It's happened before.

 

[ditch doctor]

What you are talking about is a trigger point injection. Rheumatology, Pain, Neuro, FP all do these. It's valid thing to do for muscle pain, trigger points, muscle spasm, myofascial headaches, headaches which are referred from the neck, etc. They can work. Occipital nerve blocks are easy and can be done too, for occipital headaches/neuralgia, etc. Just be remember: in a thin person's neck, you can get to the epidural or intrathecal space with a 27 gauge 1.5 inch needle and could end up with a high spinal block, if not careful, i.e. you're intubating. Also, in the upper cervical area, the foramen magnum is reachable with the same standard needle. It's happened before.

Actually, not at all. Not a trigger point injection. It is definitely not a block at all. It is just an IM injection of bupivicaine in the neck/shoulder around about 1"-1 1/2" lateral to C7, bilaterally, going in parallel to the ground. Check a C-spine CT; muscle for days there. Google cervical IM injection and Larry Mellick (if you don't know him he's an ED doc and his twin brother is a Pain doc). You can also youtube it. No where near the spine. Just in the muscles in the neck.

Just had a odontogenic abscess last night, big swollen face. 10/10 pain to 0/10 pain in less than 5 minutes. No opiods. Usually lasts a few days. Thing of beauty.

 

[Rendar5]

I agree that it's not a block, but I still consider them a form of trigger point injection. After all, you're injecting an anaesthetic to block nerve conductions that are causing pain without hitting a specific nerve.

 

[Birdstrike]

Double post

 

[Birdstrike]

Actually, not at all. Not a trigger point injection. It is definitely not a block at all. It is just an IM injection of bupivicaine in the neck/shoulder around about 1"-1 1/2" lateral to C7, bilaterally, going in parallel to the ground. Check a C-spine CT; muscle for days there. Google cervical IM injection and Larry Mellick (if you don't know him he's an ED doc and his twin brother is a Pain doc). You can also youtube it. No where near the spine. Just in the muscles in the neck.

Just had a odontogenic abscess last night, big swollen face. 10/10 pain to 0/10 pain in less than 5 minutes. No opiods. Usually lasts a few days. Thing of beauty.

I like the way you're thinking on this, but...

#1-Sticking a needle in muscle for pain relief, with or without local, is a trigger point injection (and a trigger point injection isn't a nerve block). Put lipstick on it, hair extensions, dress it up in thigh-high stockings and a thong, call it what you want, but it's still a trigger point injection.

#2-You absolutely are near the spine when sticking a 1.5" needle into the cervical paraspinal muscles as you are describing. From the article you quote, "The needle is inserted 1 to 1.5 inches into the paraspinous musculature 2 to 3cm bilateral to the spinous process of the seventh cervical vertebra."

The distance from the skin to the cervical epidural space can be as short as 4cm +/- 0.6cm (3.4 cm to 4.6 cm) which calculates to 1.3 inches to 1.8 inches. That's less than your 1.5 inch needle.

A generally benign procedure, but still can have complications. Be careful.


"Trigger-point injection therapy is a common procedure in pain management, primary care medicine, and emergency medicine and is generally considered safe. However, serious complications have been reported. These complications include pneumothorax, intrathecal injection, epidural abscess, ...Among the 276 claims...17 cases involve trigger point injections. Pneumothorax is the most common outcome of trigger point injection claims..."

Just sayin'...

Plus, are you saying you anesthetized a dental abscess by injecting bupivicaine into the cervical paraspinal muscles? You would have to block either the superior or inferior alveolar nerves, one of the branches of the trigeminal nerve, or an upper cervical nerve (C2-C4) block if in the neck, to do that. Please, clarify.

 

[Arcan57]

Can you even get compazine any more? Haven't seen it in 6 months minimum.

20mg of reglan was equal in efficacy to 10mg of compazine in an Annals article a couple of years ago.

 

[ditch doctor]

#1-Sticking a needle in muscle for pain relief, with or without local, is a trigger point injection (and a trigger point injection isn't a nerve block). Put lipstick on it, hair extensions, dress it up in thigh-high stockings and a thong, call it what you want, but it's still a trigger point injection.

This is borderline thread hijacking, but it's my thread; does that make it ok? Anyway, there is no trigger point; i.e. there is no tender spot of muscle that you inject into to disrupt. When you take off all the extensions, stockings and such, you still have have to have a dong in order to be called a dude. There just is no trigger point; a key ingredient in "trigger point" injections. This is a simple IM injection.

#2-You absolutely are near the spine when sticking a 1.5" needle into the cervical paraspinal muscles as you are describing. From the article you quote, "The needle is inserted 1 to 1.5 inches into the paraspinous musculature 2 to 3cm bilateral to the spinous process of the seventh cervical vertebra."

You go straight into the muscle, parallel to the spinous process, essentially away from the spine. I mean, yeah, you are near the spine in the sense that piercing ears is just 2 inches away from brain, but there aren't a lot of traumatic brain injuries from ear piercing.

The distance from the skin to the cervical epidural space can be as short as 4cm +/- 0.6cm (3.4 cm to 4.6 cm) which calculates to 1.3 inches to 1.8 inches. That's less than your 1.5 inch needle.

I took the same gross anatomy you did. Sure if you take a needle and go midline you run the risk. But you are not going midline. Seriously, go right now and look at a c-spine ct of an adult. Look at c7 and go about 1.5 inches lateral. Measure straight in from the in from the skin parallel to the spinous process. You are several CM away from anything. You don't angle towards the spine

A generally benign procedure, but still can have complications. Be careful.

I get that you're coming from a good place. And, seriously, residents talk to your staff, go over the literature if you are unfamiliar, and look at the youtube videos of Dr. Mellick before you just jab someone in the neck. But this is a very easy procedure with an extraordinarily low risk profile that works well. This should be in every ED docs bag of tricks.


"Trigger-point injection therapy is a common procedure in pain management, primary care medicine, and emergency medicine and is generally considered safe. However, serious complications have been reported. These complications include pneumothorax, intrathecal injection, epidural abscess, ...Among the 276 claims...17 cases involve trigger point injections. Pneumothorax is the most common outcome of trigger point injection claims..."

Again, I maintain this is just an IM injection. Not a block or trigger point injection. You would have the same risks of IM injection and using local anesthestic. Intrathecal injection and epidural injection would only happen if you do the procedure wrong. Same with a pneumo, only if you did the procedure wrong and angled down.


Plus, are you saying you anesthetized a dental abscess by injecting bupivicaine into the cervical paraspinal muscles? You would have to block either the superior or inferior alveolar nerves, one of the branches of the trigeminal nerve, or an upper cervical nerve (C2-C4) block if in the neck, to do that. Please, clarify.[/QUOTE]

Yup. All pain from the neck up. Again, this is not a block. For me personally, I have done about 60-70 in the past 4 months; it has worked on corneal abrasions, dental stuff, trigeminal neuralgia and of course headaches. The honest answer is "they" don't know how it works. I have had similar results to their trial, about 60-70% full relief, another 25-30% significant relief (9/10 down to a 4), about 5% duds; no relief. One or two people said it made their headache worse, but they were trolling for narcs. Look at the youtubes Dr. Mellick does. It even works in meningitis. (which does bring up another point; relief of a headache does not get you out of a workup, if indicated)

 

[Rendar5]

Any reason you think this is different than a trigger point injection? all my trigger point injections are soft tissue sometimes intramuscular. used it for migraine type headaches too if I can identify the specific location.

 

[Birdstrike]

#1-Sticking a needle in muscle for pain relief, with or without local, is a trigger point injection (and a trigger point injection isn't a nerve block). Put lipstick on it, hair extensions, dress it up in thigh-high stockings and a thong, call it what you want, but it's still a trigger point injection.

This is borderline thread hijacking, but it's my thread; does that make it ok? Anyway, there is no trigger point; i.e. there is no tender spot of muscle that you inject into to disrupt. When you take off all the extensions, stockings and such, you still have have to have a dong in order to be called a dude. There just is no trigger point; a key ingredient in "trigger point" injections. This is a simple IM injection.

#2-You absolutely are near the spine when sticking a 1.5" needle into the cervical paraspinal muscles as you are describing. From the article you quote, "The needle is inserted 1 to 1.5 inches into the paraspinous musculature 2 to 3cm bilateral to the spinous process of the seventh cervical vertebra."

You go straight into the muscle, parallel to the spinous process, essentially away from the spine. I mean, yeah, you are near the spine in the sense that piercing ears is just 2 inches away from brain, but there aren't a lot of traumatic brain injuries from ear piercing.

The distance from the skin to the cervical epidural space can be as short as 4cm +/- 0.6cm (3.4 cm to 4.6 cm) which calculates to 1.3 inches to 1.8 inches. That's less than your 1.5 inch needle.

I took the same gross anatomy you did. Sure if you take a needle and go midline you run the risk. But you are not going midline. Seriously, go right now and look at a c-spine ct of an adult. Look at c7 and go about 1.5 inches lateral. Measure straight in from the in from the skin parallel to the spinous process. You are several CM away from anything. You don't angle towards the spine

A generally benign procedure, but still can have complications. Be careful.

I get that you're coming from a good place. And, seriously, residents talk to your staff, go over the literature if you are unfamiliar, and look at the youtube videos of Dr. Mellick before you just jab someone in the neck. But this is a very easy procedure with an extraordinarily low risk profile that works well. This should be in every ED docs bag of tricks.


"Trigger-point injection therapy is a common procedure in pain management, primary care medicine, and emergency medicine and is generally considered safe. However, serious complications have been reported. These complications include pneumothorax, intrathecal injection, epidural abscess, ...Among the 276 claims...17 cases involve trigger point injections. Pneumothorax is the most common outcome of trigger point injection claims..."

Again, I maintain this is just an IM injection. Not a block or trigger point injection. You would have the same risks of IM injection and using local anesthestic. Intrathecal injection and epidural injection would only happen if you do the procedure wrong. Same with a pneumo, only if you did the procedure wrong and angled down.


Plus, are you saying you anesthetized a dental abscess by injecting bupivicaine into the cervical paraspinal muscles? You would have to block either the superior or inferior alveolar nerves, one of the branches of the trigeminal nerve, or an upper cervical nerve (C2-C4) block if in the neck, to do that. Please, clarify.

Yup. All pain from the neck up. Again, this is not a block. For me personally, I have done about 60-70 in the past 4 months; it has worked on corneal abrasions, dental stuff, trigeminal neuralgia and of course headaches. The honest answer is "they" don't know how it works. I have had similar results to their trial, about 60-70% full relief, another 25-30% significant relief (9/10 down to a 4), about 5% duds; no relief. One or two people said it made their headache worse, but they were trolling for narcs. Look at the youtubes Dr. Mellick does. It even works in meningitis. (which does bring up another point; relief of a headache does not get you out of a workup, if indicated)[/QUOTE]

You're anesthetizing the entire head and neck with a single IM injection of Bupivicaine into the neck at C7? For some relief of neck pain and headaches, I get it. For corneas and dental abscesses? I don't get it.

 

[ditch doctor]

You're anesthetizing the entire head and neck with a single IM injection of Bupivicaine into the neck at C7? For some relief of neck pain and headaches, I get it. For corneas and dental abscesses? I don't get it.

The Mellick brother state that they don't really understand the mechanism either, but they think it involves the trigeminocervical complex; it's in their article. And I'll be honest, the first few dental abscesses I tried this on I was truly surprised it actually worked. In fact, I kept asking them if they were just lying so they could go to a different ED where they wouldn't get a needle in the neck. They said that their pain felt better. And the relief was rapid; usually under 5 min. Same with the corneal abrasions, I've only done 2. One felt a lot better; the other felt a little better. They are all Trigeminal, so it makes sense anatomically.

http://www.ncbi.nlm.nih.gov/pubmed/18351035
http://www.ncbi.nlm.nih.gov/pubmed/17040341

 

[Groove]

Interesting. I'd like to try it but doubt I'd have the balls outside an academic shop.

 

[Rendar5]

I guess that's my point, we don't know the exact mechanism. So to state definitively that it's not a trigger point injection, despite being a myofascial injection at the location of a well-established trigger point for other pain disorders, without being able to definitely state that it is another type of injection, seems a little premature until we know more. especially since I'm not sure we even fully understand trigger points yet

I honestly don't see the harm in including it in the same category at least for now. I can, however, see the reasoning for not calling it a peripheral nerve block since we're not aiming for an identifiable nerve.

 

[WilcoWorld]

I did this injection on a patient transferred to my academic shop for a Neuro consult for status migranosus. The resident on the case had called Neuro before staffing it with me, so the Neuro service walked into the room as I was doing it. The look on their face was reason enough to try it again in a similar situation...

To me, it makes sense that it should work for tension headaches. In the rest, I'm guessing it's placebo effect (which is not to be discounted).

 

[Birdstrike]

I guess that's my point, we don't know the exact mechanism. So to state definitively that it's not a trigger point injection, despite being a myofascial injection at the location of a well-established trigger point for other pain disorders, without being able to definitely state that it is another type of injection, seems a little premature until we know more. especially since I'm not sure we even fully understand trigger points yet

Agree.

 

[Birdstrike]

To me, it makes sense that it should work for tension headaches. In the rest, I'm guessing it's placebo effect (which is not to be discounted).

Agree. Interesting, but based on retrospective reviews. For head and neck =

Before injecting bupi into the neck to numb up the eye, when you can just drop some tetracaine in the eye, please: Saline vs. bupivicaine, double-blinded, placebo-controlled trial.