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Sequence of Treatments in Emergency – what works?

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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.

*sigh*

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.

Subcutaneous Sumatriptan for Cluster Headache

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An recently updated survey of triptan for cluster studies came up with a winner:  subcutaneous sumatriptan.

Of course, there weren’t a lot of competitors.  Cluster headache is rare and therefore the studies are few.

Other contestants included the placebo (the clear loser), oral zolmitriptan and intranasal zolmitriptan.

Because cluster symptoms are so fast and furious, oral medications generall do poorly.  That leaves us with the intranasal zolmitriptan and subcutaneous sumatriptan.

Intranasal medications are taken, as you may guess, through the nose.  It’s a fast way to get medications into the body without the needle factor.

Only about 28% of patients were left with no pain or mild pain after taking the intranasal zolmitriptan.

Sumavel DosePro

Finally, subcutaneous sumatriptan.  Subcutaneous is a fancy word that usually refers to an injection.  However, medications such as Sumavel DosePro are needle-free.

Patients who took the subcutaneous sumatriptan did the best.  Three quarters had little or no pain within 15 minutes.

Learn more about subcutaneous sumatriptan here.  This article is more focused on migraine, and does warn about using sumatriptan before talking to your doctor, which is always important.

Study abstract:  Triptans for acute cluster headache.

Question: If someone has Allodynia, can they take Imitrex?

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The short answer is “yes”.  But, of course, you didn’t come here for a short answer, did you? 🙂

Years ago, many doctors became concerned that triptans such as Imitrex (sumatriptan) would not work as well once the patient developed allodynia.  (By the way, the allodynia here that we’re talking about is sensitivity/pain when the skin is touched – see My Hair Hurts! Migraine and Allodynia)  In fact, it was soon repeated over and over that triptans need to be taken early in a migraine attack (for example before allodynia hits) in order to be most effective.

Imitrex and allodynia

Now, taking medication earlier in the attack (as opposed to taking the same dose later in the attack) does seem to work better for a number of reasons.  Quite simply, as migraine triggers more and more severe symptoms, you can end up with a vicious circle of pain that is very hard to stop.

However, the relationship between triptans and allodynia may not be so simple.  For example, even if allodynia has already hit, if you take a triptan early in the attack it can still be effective (see Difference in Triptan Effect in Patients With Migraine and Early Allodynia)

Allodynia is something to be concerned about.  Not only can it be uncomfortable or even disabling, it may be a predictor of chronic migraine.  Plus, the frequent use of triptans can cause all kinds of problems, including medication-overuse headache.

So if someone has allodynia, can they take Imitrex?  Yes, they can, but:

  • They should talk it over with a doctor who knows their symptoms and medical history.
  • It’s possible that another medication may work better for them, especially if allodynia is a major symptom.
  • If they are taking Imitrex or another triptan several days a month or more, they need to seriously look at other treatment options.
  • As with many migraine abortives, it’s still recommended that you try to take something early in the attack rather than several hours later.  This applies whether you suffer from allodynia or not.

Take treatment seriously – it will help you avoid many more problems in future years.

What You Need to Know about Migraine in Emergency

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Some newly published information is aimed to help patients and help professionals understand how migraine is treated in the emergency department (ER/ED).  The Agency for Healthcare Research and Quality in the USA worked with the University of Alberta Evidence-based Practice Center in Canada to review and publish the information that has been gathering over the past few years.

Treating Severe Migraine Headaches in the Emergency Room

This information is aimed to help patients know what to expect, and to help doctors know what treatments have the best science behind them.  Treatment in emergency is unique, with special challenges.

Here are some of the basics of treatment in emergency:

  • You should especially get to emergency if your headache is very severe, if you have new or different symptoms, if you have a stiff neck or fever, or your headache starts very suddenly (especially if you’re over 50).
  • Most (though not all) medications in the ED are given by a shot or through an intravenously (IV).
  • Although pain is usually a major focus of treatment, your doctor may also need to focus on treating nausea and dehydration.

You may be disappointed with the studies’ use of the terms “migraines” and “migraine headaches”, which does tend to confuse the fact that migraine attacks, often serious ones, can come without severe headache.  And to be fair, this is a focus on treating migraine headaches specifically.  But although it’s understandable that the authors want to simplify things and use language people will recognize, I’m afraid the message will be that every migraine attack involves severe headache.

Recommended Treatments

You can use the links below to read through the material more carefully, but here are some of the treatments considered the best by the authors, based on their review of 71 clinical trials.

Of course, the “best treatment” may not be the best for you, depending on your symptoms and medical history.

Some of the most recommended treatments:

  • sumatriptan
  • neuroleptics (such as chlorpromazine or droperidol)
  • NSAIDs (such as diclofenac or ketorolac)
  • antiemetics (in particular metoclopramide)
  • opioids are useful in some instances, but now rarely used because of side effects and risk of overuse.

One more interesting treatment is dexamethasone (Decadron), which is given in order to keep the pain from returning.  It’s usually given along with another treatment, but because of the risk of side effects it’s not usually used unless the patient is at particular risk of an attack returning over the next few days.

There are other medications which may be used, and often they are used in combination (DHE may be effective in combination with other medications).  But generally the medications above have the best evidence behind them – that means fewer side effects and better results – especially relieving pain and intensity of pain.

In spite of the concerns and cautions mentioned above, this should be a useful resource so that you, as a patient, know more about what to expect and what you should discuss with your doctor.  Doctors, this will give you a quick review of the current science of treatment in the ED and ideas of what you need to discuss with your patients.

For patients:  Treating Severe Migraine Headaches in the Emergency Room
For doctors/clinicians:  Comparative Effectiveness Review Summary Guides for Clinicians

Triptans for Children and Adolescents

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Triptans, drugs developed specifically as migraine abortives, have long been used by adults.  And children too, actually.  But the adults have benefited from much better information – trials, studies … but things are improving for children.

Studies on triptans for children have suffered because of various factors.  Obviously, experimenting on children is rightly frowned upon.  Also, there’s a very high placebo effect when it comes to children.  Finally, the data is going to be, by nature, short-term.

Two drugs are approved in the USA for use with children/adolescents of various ages – rizatriptan (Maxalt) and almotriptan (Axert).

Reading through some of the study reviews, it seems that besides these, sumatriptan (Imitrex) and zolmitriptan (Zomig) have the greatest potential for treating children.

Two more important notes.  Triptans have generally been safe for children, when taken carefully under the supervision of a doctor.  A child should never be given someone else’s prescription.

Second, some triptans work in one form and not in another.  It’s very common to prescribe a nasal spray for a child, for example.  Wafer medications may also be effective.  Read more here.

Sometimes children don’t like the “aftertaste” of a nasal spray.  Try giving them a hard candy after taking the medication.

There is one more thing that is unique when it comes to child migraine.  The attack tends to pass quicker than it does in adults.  If you find that the symptoms go away just as fast without the triptan, skip the medication and try a simple home remedy.  This will avoid issues that can come with medications, and still give the child a feeling of “control” over their symptoms.

More information:

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The articles on Headache and Migraine News are © 2004-2024 J. Cottrill.
Every effort is made to ensure the accuracy of each article, and to point you to further sources of information. However, this site is for informational purposes only and should never replace a visit to your doctor.