Better treatment strategies to avoid the ER

Have you ever gone to an Emergency Room because of migraine? Most people will admit that the ER isn’t the best place to get good migraine treatment. If you’re like me, I spent way too many years being told to go to the ER if an attack got “too bad” and then being treated like a drug-seeking hypochondriac once I finally surrendered to the pain and asked for help. I would first be interrogated with questions like, “Did your doctor tell you to come here?” It was as if I lacked the intelligence or education to make that decision on my own. My response didn’t really matter either. If I was lucky, I would get a cooperative doctor who still took his or her sweet time treating my problem. Sometimes, the doctor clearly had a bias against patients with migraine, making the entire experience worse than the migraine attack itself.

A trip to the ER for an out-of-control migraine often represents a failure of our treatment plan. That plan can fail in several ways:

  • ineffective preventive treatment
  • inadequate abortive treatments
  • lack of effective rescue treatments
  • lack of education on non-medicine treatment options
  • lack of access to outpatient urgent care migraine treatment

Often these issues are a result of poor patient education on the part of the treating physician. Most primary care physicians have less than 4 hours of training in headache disorders. Many rely on pharmaceutical reps and insurance red tape to dictate their treatment protocols for migraine. With migraine affecting 1 in 4 households, one would think that medical schools would do a better job preparing students to effectively treat it. Instead, doctors wanting to know more must choose a subspecialty in headache medicine and sign on for advanced post-graduate training. There are only about 500 such doctors in the United States…about one doctor for every 76,000 migraine patients. The math just doesn’t add up.

Fortunately, some of the best minds in headache medicine have been willing to share their wisdom directly with the public. Working with these doctors, the American Migraine Foundation has released guidelines that will help all of us minimize the unfortunate use of emergency rooms.

Before you go to the ER, consider these options:

Stay well-hydrated. You’ve probably heard that deyhydration can trigger a migraine attack. Did you also know that it can make an attack more severe, more difficult to treat, and last longer? Staying hydrated during an attack can be challenging if you experience vomiting. It can be tempting to resist eating or drinking anything until the vomiting stops, but that will only make the problem worse. Even during the most stubborn attacks, remember to drink plenty of fluids.  If vomiting is a problem, ask your doctor what treatments might help slow the symptoms to prevent dehydration.

Rest in a quiet, dark room. Ice packs can do wonders, too. Sleep is a known migraine abortive, so don’t resist taking a long nap. Trying to push through your day when migraine strikes can increase the likelihood of a prolonged, intractable attack. Using dark, tinted glasses and ear plugs or headphones are a great way to block out all the noxious stimuli. I prefer total sensory deprivation during an attack, so I often use noise-cancelling headphones or silicone ear plugs, plus a cold eye mask, and even a comfortable wide-brimmed hat stuffed with ice packs.

NSAIDs are non-narcotic pain relievers such as aspirin, ibuprofen, naproxen, ketorolac, diflenolac. While these can be used to treat all kinds of pain, they may also abort a migraine attack. Some are even available over-the-counter.

Triptans are a specific class of medicines designed to abort migraine attacks. While they do not work for everyone (and may be contraindicated for some), these medicines are the only class of drugs specific to migraine. There are seven different medicines in many delivery forms. If you cannot swallow a pill due to nausea and vomiting, there are other options. You can ask your doctor about trying an injection, dissolving tablet, nasal spray, transdermal patch, or powder inhaler. These medicines can often be safely combined with NSAIDs for better results.

Anti-emetics are a great option to have readily available, too. Putting a stop to vomiting can help your body absorb the needed medicine and prevent dehydration. In a pinch, I’ve even used over-the-counter motion sickness medicine. More commonly prescribed are Compazine, Phenergan, Zofran, Reglan, and Benadryl. That’s right, Benadryl can prevent or stop vomiting. It’s also used together with triptans and NSAIDs to deliver a layered treatment to abort a migraine. My own headache specialist often recommends this combination to his patients.

I keep meticulous records of migraine attacks, probable triggers, and treatments used. When I realized that the same medicines given to me in the ER were available by prescription for home use, my doctor and I had a frank discussion. None of the meds are narcotics, so there’s no risk of dependence. I’d been limiting the use of acute pain medicines to 2 or fewer each week for years, too. Because my doctor and I have established mutual trust and respect, I am now able to have these rescue treatments available at home. I can treat an attack that is unresponsive to conservative treatments right away, saving me days of suffering and putting a stop to intractable migraine attacks quickly and comfortably at home. No interrogations, no accusations of drug-seeking, just fast, medically-appropriate relief.

Thanks to these measures, I’ve been able to avoid the emergency room for over three years. Prior to 2013, I could count on at least a half-dozen trips to the ER every year. This strategy has saved me days of pain and thousands of dollars. Maybe it’s time you gave it a try, too.

You can learn more by visiting Migraine in the Emergency Room at the American Migraine Foundation.

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