Status Migrainosus

[WilcoWorld]

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I liken it to getting IV dilaudid...all I can remember is that it felt like cool water washing over my neck and turning an almost unbearable, intense pain into a very tolerable, dull ache. At no point in time did my brain register any euphoric response whatsoever.

I dunno man, "cool water washing over my neck and turning an almost unbearable, intense pain into a very tolerable, dull ache" sounds pretty euphoric to me. In fact, I think that you wrote that quite well!

But I'm not here to take pot shots. I just wanted to point this out about IV diphenhydramine since so many on this thread (including myself) draw a hard line on opioids for migraine.

 

[Apollyon]

Brain tumors and skull fractures get opiates. Otherwise, your headache doesn't (even if you have a laminated letter from your neurologist saying "hydromorphone is the only thing that works" with you).

 

[WilcoWorld]

Brain tumors and skull fractures get opiates. Otherwise, your headache doesn't (even if you have a laminated letter from your neurologist saying "hydromorphone is the only thing that works" with you).

Your Neurologist either a) doesn't have privileges here or b) can admit you and do it themself.

No joke, I would say "that is not my practice. would you like me to try to arrange transfer to the care of your neurologist?"

 

[Apollyon]

Your Neurologist either a) doesn't have privileges here or b) can admit you and do it themself.

No joke, I would say "that is not my practice. would you like me to try to arrange transfer to the care of your neurologist?"

Dude, spot on, and here's the true story: pt comes in with this, to SC hospital. The letter is from NC neurologist. The kicker? We went to med school together. I was thinking to myself, "Dude, really?"

The climax of the story? No Dilaudid for headache.

 

[Groove]

I dunno man, "cool water washing over my neck and turning an almost unbearable, intense pain into a very tolerable, dull ache" sounds pretty euphoric to me. In fact, I think that you wrote that quite well!

But I'm not here to take pot shots. I just wanted to point this out about IV diphenhydramine since so many on this thread (including myself) draw a hard line on opioids for migraine.

Man, if someone is in REAL pain, trust me, getting high is the LEAST thing on their mind, lol. I never thought I'd stoop low enough to actually ask a nurse for pain medication in my life but that was my one exception after a few painful injuries. I think those were my first words waking up from the surgery. I croaked "Nurse....do you have anything for pain?" I'm almost ashamed that I voiced those words but damn does that stuff work when you need it! I think the surgeon had some complications....the fellow said they had my neck spread open for 3.5 hours. (I'm not condoning opioids for migraines of course....)

 

[PianoMedic]

citation plz & thx

Compazine no different than Thorazine in recent study (couldn’t find superiority when I searched):

https://doi.org/10.1111/head.14091

I am a big believer in droperidol after having used it A LOT over my first year out as an attending. I used it a bit before I completed residency. Ironically, I gave likely one of the last doses of Inapsine in the country as a paramedic in 2014 to a nauseated patient who had already received max zofran and we had it for vertiginous nausea, which this patient had. Was really excited when it came back, as it had the study linked below comparing it to compazine (droperidol superior), and another that authors concluded showed similar efficacy for migraines but the numbers were nearly there for superiority across the board aside from one outcome. Since compazine has shown superiority to reglan, I’ve even gone to it first line for some patients, usually the ones that are really thrashing around. I have seen some really bad akathisia with it though.

https://doi.org/10.1111/j.1553-2712.2001.tb01147.x

 

[thegenius]

Honestly I think you guys are wonderful caring physicians - I don't go that far. #NotAnEmergency. Toradol, tylenol, 1L NS, compazine/reglan _/- benadryl, steroids, MG all at once and orders for conditional discharge. On a handful of cases I've given VPA or fentanyl if the lobby is empty, the patient is really nice or sent by a neurologist or whatever but honestly my shop is busy and there's probably some old person with belly pain or chest pain that's waiting for this person's chair. I'd love to spend all day tinkering with this non-emergent problem but ultimately it's not serious and I need that bed for other undifferentiated patients. I've never admitted a headache patient for pain control. Am I the only one?

I haven't admitted a HA for pain control either. And correct it isn't an emergency. But sometimes we admit people who don't have emergencies.

 

[thegenius]

I've always heard this and met people with an anecdotal experience with someone who was addicted to IV Benadryl (alone) but I've never met one or seen a pt pining for Benadryl other than the opiod addicts wanting the synergistic euphoric response. I think if someone is truly suffering from a migraine, I doubt you're going to get them addicted to anything you give them IV. They just want relief from the headache. I liken it to getting IV dilaudid after I woke up from ACDF surgery. I felt like there was a molten hot rod in the center of my neck. It was excruciating and when the nurse pushed the dilaudid, all I can remember is that it felt like cool water washing over my neck and turning an almost unbearable, intense pain into a very tolerable, dull ache. At no point in time did my brain register any euphoric response whatsoever. I tend to think a true migraine pt probably feels the same way...

My general belief for real people, not bozo dickwads who are seekers,...is if they have real pain that would be responsive to opiates, when given they don't get euphoric. Their pain just goes down. It's an oversimplification but there is probably truth to it.

How many days did it take for you to overcome the hot rod poker sensaiton in your neck? Sounds absolutely terrible.

 

[Groove]

My general belief for real people, not bozo dickwads who are seekers,...is if they have real pain that would be responsive to opiates, when given they don't get euphoric. Their pain just goes down. It's an oversimplification but there is probably truth to it.

How many days did it take for you to overcome the hot rod poker sensaiton in your neck? Sounds absolutely terrible.

Agreed. I'm not a big opioid/narc dispenser in the ED but I give them for legit cases... It's funny that none of us would even be talking about any of this 10-15 years ago. We have the opioid police at my hospital audit the ED docs every month and I try to stay buried in the middle of the bell curve.

You know, it was really only when I woke up from the surgery. I'm not quite sure why it was so excruciating in my case. I fell asleep after the dilaudid and never required another dose. When I woke up it was much more tolerable. The recovery from cervical ACDF or ADR is actually really fast. I was pretty sore for the first 2-3 days but on my feet the next day and didn't require any PO pain meds other than ibuprofen. I think I was back in the gym within 2 months.

 

[WilcoWorld]

Man, if someone is in REAL pain, trust me, getting high is the LEAST thing on their mind, lol. I never thought I'd stoop low enough to actually ask a nurse for pain medication in my life but that was my one exception after a few painful injuries. I think those were my first words waking up from the surgery. I croaked "Nurse....do you have anything for pain?" I'm almost ashamed that I voiced those words but damn does that stuff work when you need it! I think the surgeon had some complications....the fellow said they had my neck spread open for 3.5 hours. (I'm not condoning opioids for migraines of course....)

No shame at all getting pain meds in the PACU!

 

[bravotwozero]

I’m similar. I usually give 10/30/25 compazine/toradol/Benadryl or swap the compazine with reglan 10 and probably 90% of the time the pts are better in half an hour and go home. I’m having a hard time thinking of the last time I had to redose a migraine pt or reach for more tools from the toolbox.

my go to tends to be reglan/toradol/Valium, works well for most.

 

[pkwraith]

Honestly I think you guys are wonderful caring physicians - I don't go that far. #NotAnEmergency. Toradol, tylenol, 1L NS, compazine/reglan _/- benadryl, steroids, MG all at once and orders for conditional discharge. On a handful of cases I've given VPA or fentanyl if the lobby is empty, the patient is really nice or sent by a neurologist or whatever but honestly my shop is busy and there's probably some old person with belly pain or chest pain that's waiting for this person's chair. I'd love to spend all day tinkering with this non-emergent problem but ultimately it's not serious and I need that bed for other undifferentiated patients. I've never admitted a headache patient for pain control. Am I the only one?

The major problem is the Patient Satisfaction (aka Harm) push from Admin. It can drives normal rational doctors who don't want to lose their jobs into things like giving Dilaudid for headaches and admitting patient that don't need to be admitted so they don't get PGs.

I've seen plenty of chronic migraine patients come in and expect to get (repeated) doses of Dilaudid and chart review actually back them up as consistently receiving them from colleagues that I have assumed to be reasonable. I'm lucky if I can get them to elope so they don't get eligible for PG.

 

[turkeyjerky]

Y'all know IV Benadryl gets people high right? And it doesn't prevent dystonic reactions better than the PO form.

I no longer order it IV unless a patient can't take PO.

But I'm not here to take pot shots. I just wanted to point this out about IV diphenhydramine since so many on this thread (including myself) draw a hard line on opioids for migraine.

Honestly, prophylactic PO benadryl sounds like a good thought to me. Part of the reason I draw a hard line on opioids for headache, though, is the risk of rebound headache. Similiar to fiocet, hate that drug.

How do you handle diphenhydramine in patients w/ SCA? I've tried a few tracts, but always end up flummoxed.

 

[WilcoWorld]

Honestly, prophylactic PO benadryl sounds like a good thought to me. Part of the reason I draw a hard line on opioids for headache, though, is the risk of rebound headache. Similiar to fiocet, hate that drug.

How do you handle diphenhydramine in patients w/ SCA? I've tried a few tracts, but always end up flummoxed.

Sorry, "SCA"?

 

[gro2001]

Honestly I think you guys are wonderful caring physicians - I don't go that far. #NotAnEmergency. Toradol, tylenol, 1L NS, compazine/reglan _/- benadryl, steroids, MG all at once and orders for conditional discharge. On a handful of cases I've given VPA or fentanyl if the lobby is empty, the patient is really nice or sent by a neurologist or whatever but honestly my shop is busy and there's probably some old person with belly pain or chest pain that's waiting for this person's chair. I'd love to spend all day tinkering with this non-emergent problem but ultimately it's not serious and I need that bed for other undifferentiated patients. I've never admitted a headache patient for pain control. Am I the only one?

We do a hell of a lot more for lots of things that are not emergencies. Just because it is not life or limb threatening, doesn't mean there isn't suffering we can fix. A bad migraine seems like a truly miserable experience. I think we are probably doing more good spending a bit of extra effort trying to relieve pain than on almost anything else we are doing, short of a legit resuscitation.

 

[DoctorJDO]

We do a hell of a lot more for lots of things that are not emergencies. Just because it is not life or limb threatening, doesn't mean there isn't suffering we can fix. A bad migraine seems like a truly miserable experience. I think we are probably doing more good spending a bit of extra effort trying to relieve pain than on almost anything else we are doing, short of a legit resuscitation.

maybe you're right. Lately it's been unclear exactly what my job role is. It used to be finding and treating emergencies, but lately it seems more like symptoms relief doctor. Historically I've been concerned with the overall health of the department - like could the 75yo abdominal pain in the lobby be an appy or AAA? by making them wait 2 more hours in the lobby for the bed occupied by this migraine patient, while I putz around trying VPA, propofol, haldol, magnesium infusions, etc is the lobby pt with belly pain going to perf their appy or have a ruptured AAA? Is that justifiable that I made them wait for this pain control case? If the lobby is empty, of course let's get these symptoms better, but at some point you have to prioritize. I realize that our jobs have slowly morphed away from treating emergencies into "fix my symptoms now" doctors, but I like to pretend that's not the case and prioritize needs over wants. 😕

 

[gro2001]

maybe you're right. Lately it's been unclear exactly what my job role is. It used to be finding and treating emergencies, but lately it seems more like symptoms relief doctor. Historically I've been concerned with the overall health of the department - like could the 75yo abdominal pain in the lobby be an appy or AAA? by making them wait 2 more hours in the lobby for the bed occupied by this migraine patient, while I putz around trying VPA, propofol, haldol, magnesium infusions, etc is the lobby pt with belly pain going to perf their appy or have a ruptured AAA? Is that justifiable that I made them wait for this pain control case? If the lobby is empty, of course let's get these symptoms better, but at some point you have to prioritize. I realize that our jobs have slowly morphed away from treating emergencies into "fix my symptoms now" doctors, but I like to pretend that's not the case and prioritize needs over wants. 😕

I am not saying that the 70s patient with abdominal pain is less important. I just don't think the migraine patient is the type of patient we should be diverting our resources away from. They are miserable, we can make them better. There are probably many other areas where we spend a lot of time/effort that we could cut back on. Agreed that old people with abdominal pain are probably not that group though.

 

[PianoMedic]

Agreed. I'm not a big opioid/narc dispenser in the ED but I give them for legit cases... It's funny that none of us would even be talking about any of this 10-15 years ago. We have the opioid police at my hospital audit the ED docs every month and I try to stay buried in the middle of the bell curve.

You know, it was really only when I woke up from the surgery. I'm not quite sure why it was so excruciating in my case. I fell asleep after the dilaudid and never required another dose. When I woke up it was much more tolerable. The recovery from cervical ACDF or ADR is actually really fast. I was pretty sore for the first 2-3 days but on my feet the next day and didn't require any PO pain meds other than ibuprofen. I think I was back in the gym within 2 months.

I have a theory on pain, my anecdotal experience with patients and your experience seems to reaffirm it some (and maybe some anesthesiologists that understand pain physiology can chime in): pain causes a hyperadrenergic state. Certain pain meds, especially opiates, are better at lysing that state. Once that state is lysed, pain improves tremendously without further interventions. I see that with sedations a lot, get the ankle back in and all of a sudden heart rate and BP drop a lot without further meds. Or when intubating and I give ketamine and would expect my normotensive or hypertensive patient to stay that way, but they go hypotensive instead (adrenals are fully maxed out and now I lysed that drive). Maybe I’m wrong, but sometimes a reasonable strong starting dose of pain med to lyse that drive can cause much longer pain control than the effective duration of the medication would indicate.

 

[DoctorJDO]

I am not saying that the 70s patient with abdominal pain is less important. I just don't think the migraine patient is the type of patient we should be diverting our resources away from. They are miserable, we can make them better. There are probably many other areas where we spend a lot of time/effort that we could cut back on. Agreed that old people with abdominal pain are probably not that group though.

maybe it's just the places I work. at any time of day there are usually 2-3 elderly patients with abnormal vitals in the lobby for 1-2+ hours waiting for a bed. most of the time I feel like it's a 1:1 exchange, every minute I spend treating symptoms from non-emergent pathology in the back (migraine, GERD, peripheral vertigo, nausea, etc) I make one lobby person wait that same amount of time to be worked up and/or treated. eventually somebody is gonna die in the lobby at some point, or have an preventable open appendectomy, or ruptured AAA, or ICH from a fall/syncope. thank you to whoever brought up the aliem tricks of the trade - I'm going to try the SPG block, seems quick and easy and might provide relief

 

[RustedFox]

maybe it's just the places I work. at any time of day there are usually 2-3 elderly patients with abnormal vitals in the lobby for 1-2+ hours waiting for a bed. most of the time I feel like it's a 1:1 exchange, every minute I spend treating symptoms from non-emergent pathology in the back (migraine, GERD, peripheral vertigo, nausea, etc) I make one lobby person wait that same amount of time to be worked up and/or treated. eventually somebody is gonna die in the lobby at some point, or have an preventable open appendectomy, or ruptured AAA, or ICH from a fall/syncope. thank you to whoever brought up the aliem tricks of the trade - I'm going to try the SPG block, seems quick and easy and might provide relief

You sound like we might work together.
Here's to yah, amigo.
*Raises glass*

At any point during my shift, I have sick seniors who need a bed that sit in the WR
for hours.

 

[VA Hopeful Dr]

Sorry, "SCA"?

Sickle cell anemia maybe?

 

[Zebra Hunter]

How do you handle diphenhydramine in patients w/ SCA? I've tried a few tracts, but always end up flummoxed.

I tell them “no, I’m not giving you Benadryl IV, but I can give you a PO dose.” Not sure what’s getting you flummoxed about sickle cell patients. Just because you feel bad for a patient doesn’t mean we have to comply with unnecessary treatments.

 

[RuralEDDoc]

maybe it's just the places I work. at any time of day there are usually 2-3 elderly patients with abnormal vitals in the lobby for 1-2+ hours waiting for a bed. most of the time I feel like it's a 1:1 exchange, every minute I spend treating symptoms from non-emergent pathology in the back (migraine, GERD, peripheral vertigo, nausea, etc) I make one lobby person wait that same amount of time to be worked up and/or treated. eventually somebody is gonna die in the lobby at some point, or have an preventable open appendectomy, or ruptured AAA, or ICH from a fall/syncope. thank you to whoever brought up the aliem tricks of the trade - I'm going to try the SPG block, seems quick and easy and might provide relief

This is why our field is so hard and frankly many of us are miserable. The stupid ethical battle that plays out every 15 minutes. Treat bad pain, or workup the potentially sick patient, and guess what you can’t do both because of beds or nurse ratios or pharmacy shortages or violent psych patients or whatever. Tough gig. Lately I’ve been like Dr DJO - giving miserable non emergencies the boot since I can’t risk the elderly abdominal pain croaking. And patients hate it.

 

[southerndoc]

Sorry, "SCA"?

Sick Crotchety A-hole

 

[lucid_leprechaun]

citation plz & thx

You’re right the study I’m referencing was the one from Headache last year, similar efficacy but different adverse event rates.

 

[Tenk]

This is how the zombie apocalypse begins: with Michael Jackson coming back from the grave and checking into an ER for more propofol.