Sequence of Treatments in Emergency – what works?

One of the most difficult challenges for someone in the middle of a migraine attack is surviving the emergency room/department.  By this time, your symptoms are so severe you can hardly think straight, and you went to the ER/ED and – you get a million questions, bright lights, strange smells, and treatments that don’t work.


So we want to do all we can to make the visit to the hospital easier for you.

To do list

Recently, Dr. Alexander Mauskop of the New York Headache Clinic suggested a sequence of treatments – a sequence that you can recommend to the doctor.

His advice especially has to do with someone who has been throwing up, and needs hydration.

Here’s a brief summary of the sequence he recommends, with some comments of my own.  You can read his whole article at:  What to ask for if your migraine lands you in the emergency room.

  1. Intravenous hydration with at least 1 gram of magnesium added to the intravenous fluids:  This really gives an excuse to get the magnesium.  Magnesium is a common and helpful migraine treatment in emergency, and can relieve a number of migraine symptoms on its own (see this study).  This approach has recently been questioned, and may work better in some cases than others.
  2. Sumatriptan (Imitrex) injection:  Best case scenario – you’ve already taken a sumatriptan injection before coming to the hospital.  If you haven’t, ask for it.  But of course be sure the doctor knows what you’ve already taken.
  3. Ketorolac (Toradol):  This is one of the recommended treatments in the new guide from the Agency for Healthcare Research and Quality in the USA and the University of Alberta Evidence-based Practice Center in Canada.  Access their recommendations here.
  4. Metoclopramide (Reglan):  Only if you’re nauseus.
  5. If the above treatments don’t help after a reasonable length of time, the doctor may try dexamethasone (Decadron) and DHE-45 (dihydroergotamine).

Dr. Mauskop emphasizes that you should not be starting your treatment with divalproex sodium (Depakene) or an opioid (such as Demerol).

Certainly these guidelines aren’t the magic bullet for everyone, but it’s good to have a place to start, and this sequence is based on some of the latest research.

Of course, you’re not going to want to go through a big explanation with clinic trials at your fingertips when you’re in emergency.  Why not make up a card which you can bring in, explaining the medications you currently take, and the recommended sequence, with links to information like the Effective Health Care Program Guide?  It might help you get better treatment faster, and you’ll only have to answer dozens of questions instead of millions.

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2 comments… add one
  • Lisa Ballard Powell Jun 16, 2014

    Oh, so true!
    I suppose I would understand if I didn’t know how severe my headaches are being put on the back burner. After all, I don’t have blood gushing out of a wound, I’m not an infant who’s choked on a toy, an elderly person suffering heart attack or stroke…you get my drift.
    But then you do get to see someone. I find myself usually in a back treatment room for long periods of time and little or no sympathy from condescending doctors and nurses who think I have no better place to go than my local ER on a drug seeking run!
    I tell them what works for me, (usually) and they say we don’t do that here or we don’t have that in our pharmacy. Would you like to try something similar? Well, actually, NO! But by then I am so worn out from the Migraine and the hospital shuffle, I’d rather go home and just throw-up and hit my head against the wall for the next 24-36 hours. And then be a walking zombie for at least two days after the Migraine’s gone.
    Best experience I ever had. An ER doctor who was himself a Migraine sufferer.

  • SUV42 Aug 6, 2014

    I have ketorolac injections at home. If you know they work, push, push, push to have them at home for self administraqtion.
    Save time making the med work better and faster. Save money and time by not needing to visit the ER. It really is a win win for the patient and medical community.

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