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Metoclopromide for Migraines

southerndoc

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    We recently reviewed the below article about the use of metoclopramide (Reglan) for treatment of migraines. The study compared metoclopramide with sumatriptan (Imitrex), and as supported by other studies, the anti-dopaminergic provided better relief than the serotonergic. (Granted the benefit from this study was limited.)

    The study gave metoclopramide 20 mg IV every 30 minutes up to a total of 80 mg. Diphenhydramine 25 mg was also given IV with the first and third doses to prevent akathesia.

    Does anyone currently use this dose? I always give 10 mg and seem to have good success with this dose. Rarely do I have to give anything else.

    Here's the article and abstract:

    Friedman, BW, et al. A trial of metoclopramide vs sumatriptan for the emergency department treatment of migraines. Neurology, 64: 463-468.

    Objective: To compare the efficacy of 20 mg of IV metoclopramide, given up to four times over 2 hours as needed for persistent headache, with 6 mg of subcutaneous sumatriptan for the emergency department treatment of migraine headaches.

    Methods: This was a randomized, double-blind, clinical trial with two intervention arms. The primary endpoint was change in pain intensity as measured by an 11-point pain scale at 2 hours. Secondary endpoints included change in pain intensity at 24 hours and rates of pain-free headache relief at 2 and 24 hours.

    Results: Two hundred two patients were screened, and 78 of 91 eligible patients were randomized. The two groups had comparable pain scores at baseline. By 2 hours, the change in pain intensity for the metoclopramide group was 7.2 compared with 6.3 for the sumatriptan group (95% CI for difference: 0.2 to 2.2). When compared at 24 hours, the metoclopramide group had improved by 6.1 compared with baseline and the sumatriptan group had improved by 5.0 (95% CI for difference: 0.6 to 2.8). At 2 hours, pain-free rates were 59% in the metoclopramide arm and 35% in the sumatriptan arm (95% CI for difference of 24%: 2 to 46%). The most common side effects at both time points were weakness, dizziness, and drowsiness, which were distributed evenly between the two groups. There were no reports of chest pain within the first 2 hours. The incidence of restlessness, stiffness, and abnormal movements was distributed equally between the two groups.

    Conclusions: When compared at 2 and 24 hours, aggressive (20 mg dosed up to four times) IV metoclopramide and 6 mg of subcutaneous sumatriptan relieved migraine headache pain comparably. Some secondary endpoints suggest that metoclopramide may be the preferable therapy for migraines presenting to the emergency department.
     
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    bulgethetwine

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      Desperado said:
      Sounds like a lot of Reglan to me. Reminds of a doc who gave 240 mg of Haldol to a patient (with predictable results.) Yes it resulted in an M&M.

      I seem to find more benefit from phenergan than from reglan, but that's purely anecdotal.

      I use the 10 dose, too. My best results (anecdotal or otherwise) have come from the following cocktail:

      10mg Reglan
      500 mg caffeine
      30 mg Toradol.
       

      DrQuinn

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        I give:
        Reglan 10 mg
        Magnesium 1 gm
        Benadryl 12.5 mg

        Benadryl also seems to help wtih some headaches but I also give it to stop any EPS side effects from Reglan. Hmmm, maybe I'll have to give a higher dose of Reglan now.

        BTW, I absolutely love caffeine for post-lp headaches, I have a 80% total cure rate with caffeine 500 mg IV over 1 hour.

        Q
         

        Apollyon

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          southerndoc said:
          Our attendings are leery of Toradol because of fears it might be a SAH.

          For initial headache, they get a head CT. If it's the same thing again, they get the cocktail.

          I got learnt my lesson as a second year - the Reglan and Toradol worked great, as I waited for the head CT - total relief of pain. What was on the CT? Posterior fossa bleed. Yeah, baby!
           

          Seaglass

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            Yes, our standard headache cocktail is Reglan/Compazine 10mg IV, Decadron 10mg IV and +/- Benadryl IV. Until last month I hadn't seen any extrapyramidal effects from Reglan/Comp, then I saw like 3 in a row. I still give it though. In my personal experience it works about 90% of the time.
             
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            spyderdoc

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              I swear by Reglan for migraines. It almost always works for the "real" migraines, yet NEVER seems to work for the "I ususlly get 4mg of Dilaudid" types.....Interestingly though, these are the ones that are always "allergic" to Reglan (as well as every other med except for the one they want). They also always seem to carry a very worn out "note" from their neurologist asking that this pt recieve a huge dose of a narcotic for their "migraine"...What, was I born yesterday?!?!
               

              GeneralVeers

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                spyderdoc said:
                I swear by Reglan for migraines. It almost always works for the "real" migraines, yet NEVER seems to work for the "I ususlly get 4mg of Dilaudid" types.....Interestingly though, these are the ones that are always "allergic" to Reglan (as well as every other med except for the one they want). They also always seem to carry a very worn out "note" from their neurologist asking that this pt recieve a huge dose of a narcotic for their "migraine"...What, was I born yesterday?!?!

                So what do you do for these people? The new JAHCO standards state that "pain is the 5th vital sign" and that all doctors/nurses notes should include a pain scale with a plan to address the pain. If the patient says he's having 9/10 pain, and is allergic to everything but Dilaudid, what do you do?

                BTW I hate the pain scale. It's the worst, most subjective piece of clinical data there is. I don't even waste my time with it.
                 

                spyderdoc

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                  GeneralVeers said:
                  So what do you do for these people? The new JAHCO standards state that "pain is the 5th vital sign" and that all doctors/nurses notes should include a pain scale with a plan to address the pain. If the patient says he's having 9/10 pain, and is allergic to everything but Dilaudid, what do you do?

                  BTW I hate the pain scale. It's the worst, most subjective piece of clinical data there is. I don't even waste my time with it.

                  I usually tell them that I will give them one shot IM (either MS 4-8mg or Dilaudid 1mg with whichever antiemetic they are not "allergic" to) and NO MORE, take it or leave it. They usually take it....

                  If they still have pain, I offer them tylenol or ibuprofen. They usually leave at this point. I make sure to document that I offered the pt non-narcotic means of pain control (tyl/ibu) and that they refused it and left...

                  I also document that the pt is in the ED with drug seeking behavior, esp if they have many similar visits......I think documenting this as well as the fact that you offered non-narcotic means to the pt will cover your butt from JCAHO.

                  I also try to tell these people to see their PMD to get referred to a chronic pain specialist so that they can get their chronic pain under control....
                   

                  WilcoWorld

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                    It should be noted that in management of headaches steroids reduce the rate of recurrence, rather than treating the acute episode. Not that that's not a desirable effect, but the distinction is worth making.
                     

                    USCDiver

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                      GeneralVeers said:
                      The new JAHCO standards state that "pain is the 5th vital sign"

                      So I've got Temp, HR, RR, BP, and SaO2... that's already 5. So I'm going to count whatever the pulse ox says as the pain measurement... wait no, that won't work... um, RR, yeah RR will also be pain measurement, and um, let's divide it by 10, too, to make it managable. Since all RNs are taught that 20 is the normal RR, the typical ER patient will have a pain measurement of 2. Likewise an increase in pain will probably cause an increase in RR and I'll have a good measure of their pain. So a 10/10 on the old pain scale equals RR of 100. Sounds about right to me. What do you guys think?
                       

                      southerndoc

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                        GeneralVeers said:
                        So what do you do for these people? The new JAHCO standards state that "pain is the 5th vital sign" and that all doctors/nurses notes should include a pain scale with a plan to address the pain. If the patient says he's having 9/10 pain, and is allergic to everything but Dilaudid, what do you do?

                        BTW I hate the pain scale. It's the worst, most subjective piece of clinical data there is. I don't even waste my time with it.

                        We have so many "5th vital signs" that it's hard to keep track of it.

                        A running tab includes:

                        1. Fingerstick blood sugar
                        2. Pulse oximetry
                        3. Pain scale
                        4. Insurance status

                        It's hard to assess a 10/10 pain on paper. Some patients are in tears with their 10/10 pain while others are cutting up and telling jokes with their 10/10 pain.
                         

                        southerndoc

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                          Apollyon said:
                          That is so nerdy and funny - I wonder who knows their bones?
                          Bone of the feet/ankle are no problem for me... I always have trouble with the stupid bones of the hand. Can never keep them in proper order.

                          Thank God for Google!
                           
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                          GeneralVeers

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                            southerndoc said:
                            We have so many "5th vital signs" that it's hard to keep track of it.

                            A running tab includes:

                            1. Fingerstick blood sugar
                            2. Pulse oximetry
                            3. Pain scale
                            4. Insurance status

                            It's hard to assess a 10/10 pain on paper. Some patients are in tears with their 10/10 pain while others are cutting up and telling jokes with their 10/10 pain.

                            Very true. This "5th vital sign" stuff is BS to me. All of the ED patients I see are in pain all of the time, so it's a superfluous measurement in non-trauma patients.

                            I use my own pain scale. If I have to wake you up to do an H&P, or if you repeatedly fall asleep while I'm talking to you (happened yesterday) then your pain is automatically <5. Subtract additional points for talking on your cell phone in the ED, repeatedly asking when your free food will arrive, or telling me that you are in a hurry and need to leave by 2 PM.
                             

                            DrQuinn

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                              I herniated a disc in my back during my internship... pretty painful stuff. My wife is a physical therapist so I was having her take a look at me. She asked me my pain scale... I told her 4/10. She said "that's nothing!" I said, "listen, hooker, I'm using the REAL pain scale...."

                              Q
                               

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                                QuinnNSU said:
                                I herniated a disc in my back during my internship... pretty painful stuff. My wife is a physical therapist so I was having her take a look at me. She asked me my pain scale... I told her 4/10. She said "that's nothing!" I said, "listen, hooker, I'm using the REAL pain scale...."

                                Q


                                I had a spontaneous pneumothorax once. It was the only time I've ever been in so much pain that I was flat on the floor for a good 2 hours. To me that's 8/10 pain.
                                 

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                                  When I was on my neurology clerkship last year, I ended up in the ED with a migraine. I have significant family history for head bleeds, so of course I got a CT and a tap. Once they got fluids into me (as I had been puking all day), and my 10 of Reglan, I was a happy camper. Of course, I also spend a week working the neuro wards with an lp HA. One of the neurologists made me go to his clinic to stock up on some Maxalt. Love the stuff - but in the ED the Reglan worked great for me. :thumbup:

                                  MJ
                                   

                                  jlw2004

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                                    GeneralVeers said:
                                    If the patient says he's having 9/10 pain, and is allergic to everything but Dilaudid, what do you do?

                                    If I ever see a pt with "9 out of 10" pain, they get my full attention much more quickly than the usual pt with '10 out of 10" pain who is usually talking on the phone eating cheetos.
                                     

                                    bcsmith

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                                      Oh, and as for the pain scale - I've always wanted to carry around picture of an open tib/fib fx. When the patient says "man... it's definitely a 9 or 9.5," I pull out the pic and say "this is a 10, now whats your pain?"

                                      b
                                       

                                      stoic

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                                        no kidding about the pain scale being useless some of the time. i saw this one guy who to have 9/10 who was moving just fine, no increased BP/HR, talking fine... when you try to reproduce the pain (even in a different dermatome) and ask "does this hurt" he said "oh yea,... ouch" and then went back to being annoyed that the exam is taking so long. he actually had the nerve to say "tylenol III? that's it? i'll just take the percocet i have at home." he actually did have an inguinal hernia, but wouldn't you know it, failed to follow up for his surgery appt. the next day.

                                        and in some patients i think it's just a function of not having had a lot of pain to compare their current level too. but if your pain is truly like 6 or 7/10, you should be having appropriate reactions to it. if you seem completely normal, then i think you're lying. maybe i'm a jerk... or maybe i think that if people want their narcs, they should have to act a little for them.


                                        anyway, back to migranes. do you guys ever use narcotics for migranes/HA's anymore? my ED time is mostly in small, non-academic centers in rural-ish kansas and unless we have a note from the patients doctor asking for no-narcs or the person is showing up for migranes all the time, they usually get whatever they want (which is usually narcotics, but occasionally toradol).
                                         
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                                        GeneralVeers

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                                          stoic said:
                                          no kidding about the pain scale being useless some of the time. i saw this one guy who to have 9/10 who was moving just fine, no increased BP/HR, talking fine... when you try to reproduce the pain (even in a different dermatome) and ask "does this hurt" he said "oh yea,... ouch" and then went back to being annoyed that the exam is taking so long. he actually had the nerve to say "tylenol III? that's it? i'll just take the percocet i have at home." he actually did have an inguinal hernia, but wouldn't you know it, failed to follow up for his surgery appt. the next day.

                                          and in some patients i think it's just a function of not having had a lot of pain to compare their current level too. but if your pain is truly like 6 or 7/10, you should be having appropriate reactions to it. if you seem completely normal, then i think you're lying. maybe i'm a jerk... or maybe i think that if people want their narcs, they should have to act a little for them.


                                          anyway, back to migranes. do you guys ever use narcotics for migranes/HA's anymore? my ED time is mostly in small, non-academic centers in rural-ish kansas and unless we have a note from the patients doctor asking for no-narcs or the person is showing up for migranes all the time, they usually get whatever they want (which is usually narcotics, but occasionally toradol).


                                          If the patient is asleep, and I have to shake them to wake them up, they are automatically at 5 or below on the pain scale regardless of what number they give me.

                                          I never give narcs for headaches, usually anti-emetics, fluids, and/or Toradol initially. If I have to go to narcs then they're probably going to get a head CT as well.
                                           

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                                            Definitely true...

                                            GeneralVeers said:
                                            If the patient is asleep, and I have to shake them to wake them up, they are automatically at 5 or below on the pain scale regardless of what number they give me.

                                            Why?

                                            GeneralVeers said:
                                            I never give narcs for headaches, usually anti-emetics, fluids, and/or Toradol initially. If I have to go to narcs then they're probably going to get a head CT as well.
                                             

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                                              spyderdoc said:
                                              I usually tell them that I will give them one shot IM (either MS 4-8mg or Dilaudid 1mg with whichever antiemetic they are not "allergic" to) and NO MORE, take it or leave it. They usually take it....

                                              If they still have pain, I offer them tylenol or ibuprofen. They usually leave at this point. I make sure to document that I offered the pt non-narcotic means of pain control (tyl/ibu) and that they refused it and left...

                                              I also document that the pt is in the ED with drug seeking behavior, esp if they have many similar visits......I think documenting this as well as the fact that you offered non-narcotic means to the pt will cover your butt from JCAHO.

                                              I also try to tell these people to see their PMD to get referred to a chronic pain specialist so that they can get their chronic pain under control....


                                              Do you do this with ALL pts presenting with migraine or just the ones you KNOW are "drugseeking"? Its been so long since I've been here I forget if we had this convo already ! If we did....my deepest aplogies. ;)

                                              Please everyone...Don't jump down my throat or insult me or make fun of me or make a dig at me....I'm just asking a question. :oops: ...you may be having bad day for all I know..or dealt with 20 or so migraineurs during shift :laugh:

                                              By the way....8 months with only 2 migraines..NO ER visits :D and yes///metoclopromide is awesome...except I can't get more than 10mg due to akathesia....
                                               

                                              spyderdoc

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                                                Katee80 said:
                                                Do you do this with ALL pts presenting with migraine or just the ones you KNOW are "drugseeking"? Its been so long since I've been here I forget if we had this convo already ! If we did....my deepest aplogies. ;)

                                                Please everyone...Don't jump down my throat or insult me or make fun of me or make a dig at me....I'm just asking a question. :oops: ...you may be having bad day for all I know..or dealt with 20 or so migraineurs during shift :laugh:

                                                By the way....8 months with only 2 migraines..NO ER visits :D and yes///metoclopromide is awesome...except I can't get more than 10mg due to akathesia....

                                                Mostly the ones with MULTIPLE ED visits and/or multiple allergies. I think with experience, one gets a keen sense of sniffing out the drug seekers...

                                                I do this not only for migraines, but the other varieties of chronic pain folks as well....The back pain variety, and especially the new "cyclic vomiting" psycho nuts. I've had a rash of these in the last year....It seems that they all want morphine, and a lot of it, to make their vomiting stop...

                                                The one type of chronic pain folk that I really take seriously and actually feel bad for are the sicklers.....They actually have real disease with real manifestations, and die young with painful deaths...Some do take advantage of the system and have frequent visits, but I still usually give them the benefit of the doubt and treat their pain pretty aggessively, and have a low threshold to admit them.....
                                                 

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                                                  spyderdoc said:
                                                  The one type of chronic pain folk that I really take seriously and actually feel bad for are the sicklers.....They actually have real disease with real manifestations, and die young with painful deaths...Some do take advantage of the system and have frequent visits, but I still usually give them the benefit of the doubt and treat their pain pretty aggessively, and have a low threshold to admit them.....

                                                  after awhile treating the kids (peds resident here) with standard doses is like p*ssing on a brushfire.

                                                  we use IV toradol, IV morphine/dilaudid (often PCA for a basal and demand dosing) and fluids (after ACS ruled out) and do it aggressively. once you get behind it's hard to get back on top of it. we've had kids on the floor for multiple days with pain crises. they definitely suck.

                                                  --your friendly neighborhood malaria resistance ain't worth all that caveman
                                                   

                                                  stoic

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                                                    did a shift in my hometown ED last night and had a long talk with the docs about why they still use lots of narcotics, especially demerol, for the migraine folks. though they concede that reglan/toradol is a fine cocktail for migraines - and they do use it for first migraines or if pt's are willing to give it a fair shot - here are the reasons they don't fight people who demand narcotics:

                                                    1) trying to give pt's the benifit of the doubt. maybe it's old-fashioned, but if they have a patient you says that narcotics work best and who isn't clearly abusing the system to get drugs, they'll go ahead and give them what they want.

                                                    2) resources. it's a small ED that usually has one physician and one extender with a handful of nurses. if they have someone who isn't leaving until they get what they want, it can take several hours to babysit them while they try triptans, then anti-emetics, then finally less powerful narcotics, and finally whatever the patient is demanding. so most of the time they'll go ahead and give narcs if the person is persistant - unless they are a known abuser, in which case they give toradol and tramadol and tell them to make sure "not and drive home." it works to trick them occasionally.

                                                    and we actually had a migraine pt. last night who got the demerol/phenergan they wanted. she comes in about 3 or 4 times a year, sees a neurologist, takes beta-blockers prophylactically and isn't a total ass about demanding demerol. just states that it usually works best. so she got 75mg, the phenergen, and litererally was out of the department 20 minutes after coming back.

                                                    so i'm not really taking sides here; at least not until i'm further in my training. but these guys are physicians i respect (hell, 2 of them even wrote me letters of recommendation when i was applying to med school) who have been doing this longer than most everyone on the board (w/the exception of maybe docB and ERmudphud), so i do hesitate to say they're doing it "wrong" by giving these pt's narcotics.

                                                    anyway, katee80, next time you've got a migraine, just come to kansas.
                                                     

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                                                      GeneralVeers said:
                                                      I had a spontaneous pneumothorax once. It was the only time I've ever been in so much pain that I was flat on the floor for a good 2 hours. To me that's 8/10 pain.

                                                      Kidney stone = 10/10 for me. I thought that burning my face in an engine fire was pain, but the pain from the stone left me vomitting and on the verge of passing out. I thought I was dieing. Fortunately, the doc in the ED could tell that I wasn't screwing around and quickly cleared me from anything else and made morphine my new friend.
                                                       

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                                                        A couple of months ago someone posted a sample document along the lines of "Dear Patient... In the interests of providing you with the best possible care, we have the following protocol for treating chronic pain in the ED". There were a couple of iterations of it for migraine/back pain, etc. I remember thinking it was an attractive idea, but now I can't find that link when I search for it. I have done searches under migraine/chronic pain/pain protocol/ and many others, but still no luck. Does anyone remember where it is or who posted it? I'm pretty sure it was here in the Emergency Medicine forum.

                                                        Thanks.
                                                         

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                                                          Bump...

                                                          Anyone remember the post from a couple of months ago that I am trying to find?

                                                          "A couple of months ago someone posted a sample document along the lines of "Dear Patient... In the interests of providing you with the best possible care, we have the following protocol for treating chronic pain in the ED". There were a couple of iterations of it for migraine/back pain, etc. I remember thinking it was an attractive idea, but now I can't find that link when I search for it. I have done searches under migraine/chronic pain/pain protocol/ and many others, but still no luck. Does anyone remember where it is or who posted it? I'm pretty sure it was here in the Emergency Medicine forum"

                                                          --Highdesert
                                                           
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