Status Migrainosus

[thegenius]

Anyone ever use propofol in these patients?

There are a spat of studies showing bolusing small doses of propofol can help. I've been angling to do this...and finally did the other day.

This 38 yo F has a history, per the neurologist, of intractable migraines that may be due to PRES she suffered from many months ago. So I'm not totally sure if she had true migraines or some other HA from PRES. Anyway she is in the convalescent phase and for the past few months but still suffering from migraines, and the HA she had yesterday was the same as priors. After ketorolac, compazine, benadryl, and IVF didn't really help (pain still 8/10), I offered to give her small propofol doses and she agreed. The nurse was like "wat you wanna do? you push it" and I was happy to do so.

I looked up a protocol and gave 20 mg IVP q5 minutes up to 120 mg or until her HA went to 0. I ended up giving all 120 mg. She was monitored the entire time, never had a whiff of any problems from propofol. She fell asleep and snored but unfortunately her HA went down to 4/10. But she was happy we tried.

Not a resounding success but I'm willing to try it again. Only problem is I was in there for 30 minutes...
Anybody have success doing this?

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[RustedFox]

Yeah, I'm not doing this simply because every *ostrich* in the area will now have "migraine headaches".

 

[DrDrummer]

Yeah, I'm not doing this simply because every *ostrich* in the area will now have "migraine headaches".

This x 100 and as someone who has been on committees that looked over procedural sedation quality metrics and reviewed cases that went wrong (rare, but they happen), I think this would be a tough one to defend the necessity of doing in the ER. I remember thinking this when Rick Pescatore wrote a column about it in one of those mailers. I would try Reglan, nerve blocks or an anti-epileptic before I would use Propofol for migraine.

 

[RustedFox]

Especially at my shop. The ostrich index is out of sight.

 

[PianoMedic]

This x 100 and as someone who has been on committees that looked over procedural sedation quality metrics and reviewed cases that went wrong (rare, but they happen), I think this would be a tough one to defend the necessity of doing in the ER. I remember thinking this when Rick Pescatore wrote a column about it in one of those mailers. I would try Reglan, nerve blocks or an anti-epileptic before I would use Propofol for migraine.

Gotta agree here. I’ve had good luck with droperidol and before that haldol in compazine refractory migraines. I’ve called neuro a handful of times for one of their patients and they’ve recommended valproic acid and magnesium. I haven’t done that without consulting them yet as I don’t know dosing (someone smarter than me feel free to let me know so I can start going to that after droperidol doesn’t work).

 

[thegenius]

This x 100 and as someone who has been on committees that looked over procedural sedation quality metrics and reviewed cases that went wrong (rare, but they happen), I think this would be a tough one to defend the necessity of doing in the ER. I remember thinking this when Rick Pescatore wrote a column about it in one of those mailers. I would try Reglan, nerve blocks or an anti-epileptic before I would use Propofol for migraine.

Perhaps...I'm not even sure this would be "procedural sedation" though. Perhaps.

In any event there is not one but several studies that show a potential benefit.

What nerve block is there for a migraine HA?

 

[PianoMedic]

Perhaps...I'm not even sure this would be "procedural sedation" though. Perhaps.

In any event there is not one but several studies that show a potential benefit.

What nerve block is there for a migraine HA?

A few places, the main one I’ve seen is the occipital nerve. I think in theory there are others such as supraorbital nerve. Had a talk from a plastic surgeon on that and I’ve totally forgotten everything about it except for occipital nerve.

 

[Zebra Hunter]

This x 100 and as someone who has been on committees that looked over procedural sedation quality metrics and reviewed cases that went wrong (rare, but they happen), I think this would be a tough one to defend the necessity of doing in the ER. I remember thinking this when Rick Pescatore wrote a column about it in one of those mailers. I would try Reglan, nerve blocks or an anti-epileptic before I would use Propofol for migraine.

Yeah, I remember having a debate with Rick on Twitter about this whenever he first started recommending it. Without any moderate quality literature to support its use, I’m not sure it’s a good idea for any EM doc to be doing this when there is major risks (albeit rare) and it being so far outside of standard care for migraines the ER. Also, the nurses will hate you for it.

 

[thegenius]

Lovely I don't have the support of my fellow ER docs

(I did give the standard of care for migraines first, and it didn't work.)

 

[thegenius]

I think this is akin to giving low-dose ketamine like 0.15-0.3 mg / kg IV for intractable abdominal pain refractory to opioids. There are risks with ketamine, just like with propofol, and the studies for low dose ketamine are few, just like the studies for propofol for migraines.

 

[southerndoc]

One of our docs a while back read a study and decided he wanted to try ketofol. Of course the patient's migraines were "only" cured with Dilaudid. I use droperidol exclusively.

 

[lymphocyte]

I think this is akin to giving low-dose ketamine like 0.15-0.3 mg / kg IV for intractable abdominal pain refractory to opioids. There are risks with ketamine, just like with propofol, and the studies for low dose ketamine are few, just like the studies for propofol for migraines.

I love low dose ketamine too and use it liberally for analgesia. Sometimes I use it instead of opioids/opiates altogether especially on folks already on methadone or buprenorphine. Great for chest trauma too.

I mix it up with 100mLs N/S and give it as a slow infusion over 15 to 30 minutes to minimise the side effects.

Not much evidence for propofol in status migrainousus, and I'd get dirty looks from my nurses. Two RCTs showed it's no better than placebo. Fantastic anti-emetic though.

I usually give some combination of 6mg Sumitriptan S/C, 15mg Keterolac IMI, 12.5mg Chlorpromazine in 500mL N/S + 20mmol MgSO4, and/or 12mg Dexamethasone IV. If this is ineffective, I strongly reconsider the diagnosis. But you have to treat the patient in front of you.

Brother I think you did great. Tried something new. Grounded in literature. Grateful patient. I'd give it a whirl if it came to that.

https://www.jwatch.org/na52743/2020/11/03/low-dose-ketamine-viable-option-control-acute-pain-ed

Piatka C and Beckett RD. Propofol for treatment of acute migraine in the emergency department: A systematic review. Acad Emerg Med 2019 Oct 16. https://doi.org/10.1111/ACEM.13870

 

[Groove]

Anyone ever use propofol in these patients?

There are a spat of studies showing bolusing small doses of propofol can help. I've been angling to do this...and finally did the other day.

This 38 yo F has a history, per the neurologist, of intractable migraines that may be due to PRES she suffered from many months ago. So I'm not totally sure if she had true migraines or some other HA from PRES. Anyway she is in the convalescent phase and for the past few months but still suffering from migraines, and the HA she had yesterday was the same as priors. After ketorolac, compazine, benadryl, and IVF didn't really help (pain still 8/10), I offered to give her small propofol doses and she agreed. The nurse was like "wat you wanna do? you push it" and I was happy to do so.

I looked up a protocol and gave 20 mg IVP q5 minutes up to 120 mg or until her HA went to 0. I ended up giving all 120 mg. She was monitored the entire time, never had a whiff of any problems from propofol. She fell asleep and snored but unfortunately her HA went down to 4/10. But she was happy we tried.

Not a resounding success but I'm willing to try it again. Only problem is I was in there for 30 minutes...
Anybody have success doing this?

I tried this for the first time back in 2014 or so after reading Intravenous propofol: unique effectiveness in treating intractable migraine - PubMed and discussing it with a colleague of mine that was on shift. It looks like there have been a few more low powered studies since then. I've only tried it maybe 3 times over the years. Although it worked pretty well...the downtime, nursing histrionics, and paperwork (I don't think I ever was able to convince nursing that we could avoid procedural sedation paperwork, etc..) didn't make it worthwhile to me. Plus, it's really uncommon for me to have to admit status migrainosus pt's in the first place where I can't get any control of their headache and end up not worried that something else is going on... The ones that I can't get control, I'm always suspicious of some sort of supratentorial component. In hindsight, I'm convinced one of my propofol pt's was 80% psych and the propofol just blitzed her back into happy land.

I don't think there's anything wrong with it though if you're having good results and aren't getting a lot of nursing push back. It's good thinking outside the box. It reminds me of a ketamine infusion protocol that I started using awhile back for refractory trigeminal neuralgia that I've had excellent results with over the years and have done it on 5 or so patients with 100% success so far. Comparative Study between Intravenous Ketamine and Lidocaine Infusion in Controlling of Refractory Trigeminal Neuralgia. I actually do a really slow bolus at bedside because the infusion slows nursing down and I don't like to leave the room while it's infusing.

 

[Groove]

I must have the worst luck with analgesic ketamine doses. It seems like I get all the dysphoric, disassociated pt's that flip out and start hysterically screaming or crying. I've gotten to where I hate using it for pain in the ED.

 

[PianoMedic]

I must have the worst luck with analgesic ketamine doses. It seems like I get all the dysphoric, disassociated pt's that flip out and start hysterically screaming or crying. I've gotten to where I hate using it for pain in the ED.

Had ketamine work well once and only once. Tried maybe a half dozen times and even doing 0.2 or 0.3 mg/kg I end up with people flipping out and they hate it. I do use it with a lot of my procedural sedations in all comers to reduce total propofol dosing (I use 0.5 mg/kg, and don’t mix in the syringe with propofol but use separately). Typically only for sedations I think will take more than 15 minutes or so though. Less than that I’ll just keep bolusing propofol typically.

 

[Mr. Vandemar]

I give the 0.3mg/kg over 15 min - 30 min, never had any issues with people freaking out.

 

[Fox800]

Yeah, I wouldn't do propofol for this in the ED.
Compazine, APAP, NSAID, magnesium, droperidol...after that might consider sumatriptan, depakote or ketamine. If I'm at depakote/ketamine then I'm talking to neurology and/or admitting them to observation. Or might try a greater occipital nerve block, had luck with that n=1.

 

[lp430]

Wasn't there a NYC ER doc that gave propofol to abuse patients while in a room with them alone? (Obviously an extreme example)
I'd avoid it for the optics alone. I'll stick with my droperidol/Haldol.

 

[Apollyon]

Wasn't there a NYC ER doc that gave propofol to abuse patients while in a room with them alone? (Obviously an extreme example)
I'd avoid it for the optics alone. I'll stick with my droperidol/Haldol.

Yeah, David what's his name. St. Luke's/Roosevelt. Or was it Mt. Sinai?

 

[GassYous]

I must have the worst luck with analgesic ketamine doses. It seems like I get all the dysphoric, disassociated pt's that flip out and start hysterically screaming or crying. I've gotten to where I hate using it for pain in the ED.

Give midaz

 

[turkeyjerky]

I usually give some combination of 6mg Sumitriptan S/C, 15mg Keterolac IMI, 12.5mg Chlorpromazine in 500mL N/S + 20mmol MgSO4, and/or 12mg Dexamethasone IV. If this is ineffective, I strongly reconsider the diagnosis. But you have to treat the patient in front of you.

You really give thorazine for migraines? You sure you didn't mean promethazine?

I disagree that the response, or lack thereof, to abortive therapy should effect one's diagnosis. I've definitely seen increased ICP and SAHs respond well to migraine cocktails.

Back to the OP. I'm in the pro column. I've haven't done this personally, but see absolutely no reason not to. It's definitely not procedural sedation, imho.

 

[WilcoWorld]

Wasn't there a NYC ER doc that gave propofol to abuse patients while in a room with them alone? (Obviously an extreme example)
I'd avoid it for the optics alone. I'll stick with my droperidol/Haldol.

Yeah, David what's his name. St. Luke's/Roosevelt. Or was it Mt. Sinai?

David Newman

 

[WilcoWorld]

I swear it feels like it's been so long since I had a nice migraine case, so I haven't had the opportunity.

I think, in the right patient (a real migraneur who doesn't seem like they abuse the ED) if my escalating attempts have failed, I'd try this approach if it could avoid an admission. With appropriate consent and documentation (and safety precautions) I wouldn't be scared off by fear of rare complications or clipboard scrutiny.

 

[AlmostAnMD]

I, too, am in the crowd of no longer using LDK.

Story time.

Had mixed results with it. Hospital policy required nurses to monitor patients receiving it (still classified as a "sedation"--I don't make the rules) so of course every nurse ever was a bitch whenever it was ordered instead of medication not requiring sedation charting.

A single patient stopped my use. Did the 0.1 mg/kg dose over 15 minutes. Halfway through her heartrate shot up to 140ish and she started making weird groaning noises. Her husband freaked out and, not adding any help, began to panic which fed the patient's own panic cycle forward.

We were doing all this under the supposition that it was not "dissociative" at this dose. Nurse began to shake the patient--and I will always remember this--firmly maintained eye contact with me as she asked the patient, "ARE YOU FEELING DISSOCIATED?" A word that the patient had clearly never heard before. After the "sedation" RN immediately went to charge RN to inform her I had dissociated the patient when the patient answered, "yes." Of course, she could could have said "yes" to just about anything there since this homeless person probably couldn't spell or understand what that meant and just answered a leading question the way it was meant to be answered.

Never again. Not worth the hate. This story flashes to my mind when asking about propofol, so I doubt I'll ever try it. No longer a literature cowboy.

Still use ketamine for sedation though. For migraine I have reasonable success with various cocktails. Reglan/benadryl works for people that aren't crazy. I can up it with toradol decadron and a mag infusion for people that aren't crazy. For people that are crazy I just keep pushing droperidol, titrating to STFU. You push enough of it, they can't tell you their head hurts.

If that sounds burned out I'm typing it right

 

[Cinclus]

Does anybody else do the sphenopalatine ganglion block for migraines? So danged easy, fast, and, in my experience, pretty effective. Just
(gently) shove a lidocaine-soaked cotton swab up the nose on the side of the head that hurts. Everyone thinks I'm nuts when I do it, but then they think I'm magic. I've had this work when IV meds have failed.

Details:

Trick of the Trade: Sphenopalatine Ganglion Block for Treatment of Primary Headaches

Trick of the Trade: Sphenopalatine Ganglion Block for the treatment of primary headaches - an alternative or adjunct -- by Drs. Jeff Shih and Chris Gaafary

www.aliem.com

 

[Mount Asclepius]

I rarely use LDK anymore as well. I've had too many 'normal' patients experience bad trips with just even 0.1 mg/kg. I'll still use it for femur fractures (mixed success), but not for headaches or abdominal pain.

I don't use Propofol for treatment of pain. I'm not going to throw the book at someone who wants to give it a try. Just not something I'd probably do. Most nurses don't have a ton of familiarity with non-procedural sedation Propofol. I wouldn't get much pushback, but maybe raised eyebrows. I'd be willing to push myself, but I certainly wouldn't do it alone in a room with a patient (i.e. Newman).

Status migrainosus isn't an emergency. It rarely can be disabling, but it's so rarely refractory to basic treatment. Almost all respond to Toradol, Compazine, Benadryl, Dexamethasone and IVFs. For those that don't, I'll give Sumatriptan (if the patient hasn't already taken), Ofirmev, Magnesium and Depakote. I don't use opioids. If they have opioid rebound headaches, then I counsel them on my concerns regarding their opioid use. I use Lidoderm patches, Flexeril and trigger point injections if I suspect a tension component. If there is still a refractory headache, I first reconsider the differential. Am I still confident that no advanced neuroimaging is necessary? If so, then I have a frank discussion with patients letting them know that I might not be able to make their pain go all the way away, but hopefully have made it tolerable. If they don't feel it is tolerable then it is potentially neurology consultation plus/minus admission. The vast majority are sleepy after Benadryl, their pain is significantly improved, and they'd prefer to go home to sleep in their own bed. The rest are usually homeless with secondary gain needing a place to sleep, have a supratentorial component (in which case might consider Haldol/Droperidol), and perhaps a small group of patients might benefit from neurology weighing in.

If that sounds burned out I'm typing it right

 

[Rockinacoustic]

I've worked with 40+ Docs between two depts and only saw it done twice. Both were before droperidol returned to market.

 

[end stage fibro]

I think this is akin to giving low-dose ketamine like 0.15-0.3 mg / kg IV for intractable abdominal pain refractory to opioids. There are risks with ketamine, just like with propofol, and the studies for low dose ketamine are few, just like the studies for propofol for migraines.

When i was a resident, there was an advanced gyn guy who would frequently admit pts together with a neurologist. Would snow pts for about a week with ketamine and some other stuff I don’t recall, plus some bladder overdistension. Pts woke up feeling great. I’m shocked to see mention of ketamine in similar capacity again nearly 10 years later

 

[Janders]

I agree the low dosing (20mg q5 min in an adult shouldn’t get you passed anxiolysis after a couple rounds…) of propofol is likely extremely safe. Still would need to either pass it through P&T as a “non-sedation” use of propofol [good luck] or just pony up and run it like a sedation with a dedicated RN, monitoring and charting. I wouldn’t have any specific quality concerns if someone wanted to do it where I work, as long as they had some degree of discussion of risk/benefit/alternative with the patient and documented it. I would be more concerned about tying up limited resources and having 3 patients LWBS while you give homeopathic propofol for 40 minutes . Still I can image situations where it would be reasonable to try, could avoid an admission etc.

All that said, my migraine pathway of (1) Reglan or Compazine / Benadryl / Toradol +1L NS, (1b) Haldol or Droperidol, (2) Magnesium 2gm IV + Decadron 8mg IV… by then 98% of migraines are very much better or just want to leave with a moderate headache. I’ve used Valproate after this, and in select patients Imitrex or Occipital blocks. I’ve tried the sphenopalantine lidocaine a couple times without wonderful results, but would again.

So yeah, propofol would be 7th or 8th line in my toolbox and I don’t ever get there. Its above Dilaudid though.

 

[pkwraith]

I do ketamine for refractory migraine, and in some of the smaller hospitals, some of the nurses would lose their ****. I can't imagine what they would do if I started doing propofol.

 

[southerndoc]

Does anybody else do the sphenopalatine ganglion block for migraines? So danged easy, fast, and, in my experience, pretty effective. Just
(gently) shove a lidocaine-soaked cotton swab up the nose on the side of the head that hurts. Everyone thinks I'm nuts when I do it, but then they think I'm magic. I've had this work when IV meds have failed.

Details:

Trick of the Trade: Sphenopalatine Ganglion Block for Treatment of Primary Headaches

Trick of the Trade: Sphenopalatine Ganglion Block for the treatment of primary headaches - an alternative or adjunct -- by Drs. Jeff Shih and Chris Gaafary

www.aliem.com

Works great until the lidocaine wears off and then it's a thunderclap headache. I know because I treat my migraines this way and do it myself every 3 hours for 24 hours. That's the only way I can keep from getting a rebound headache when the lidocaine wears off (by not allowing it to wear off). I use 3% lidocaine gel. Feels like a Covid swab going in. LOL

 

[RuralEDDoc]

Also stopped using low dose ketamine - between the bad trips which seem to be common and nursing pushback, not worth it for something that has other options. Might try again in a sickle cell patient if the multi dose opiates and toradol don’t help since there’s no great options there.
There’s no way in hades that I’ll be able to pull off propofol for headache. My hospitals just aren’t that progressive, plus, who needs to create another class of propofol seeking patients.

 

[wook]

I have had reasonable luck using ketamine 0.15-0.3 mg/kg put in a 100 ml NS bag and run over 30 minutes. No problems since running it over the longer period of time. No dissociation, no dysphoria.

 

[thegenius]

Does anybody else do the sphenopalatine ganglion block for migraines? So danged easy, fast, and, in my experience, pretty effective. Just
(gently) shove a lidocaine-soaked cotton swab up the nose on the side of the head that hurts. Everyone thinks I'm nuts when I do it, but then they think I'm magic. I've had this work when IV meds have failed.

Details:

Trick of the Trade: Sphenopalatine Ganglion Block for Treatment of Primary Headaches

Trick of the Trade: Sphenopalatine Ganglion Block for the treatment of primary headaches - an alternative or adjunct -- by Drs. Jeff Shih and Chris Gaafary

www.aliem.com

I like this. Looks really easy

 

[lymphocyte]

You really give thorazine for migraines? You sure you didn't mean promethazine?

I do. Chlorpromazine is actually in our national therapeutic guidelines here in Australia if triptans fail. Works quite well.

 

[gro2001]

Anyone ever use propofol in these patients?

There are a spat of studies showing bolusing small doses of propofol can help. I've been angling to do this...and finally did the other day.

This 38 yo F has a history, per the neurologist, of intractable migraines that may be due to PRES she suffered from many months ago. So I'm not totally sure if she had true migraines or some other HA from PRES. Anyway she is in the convalescent phase and for the past few months but still suffering from migraines, and the HA she had yesterday was the same as priors. After ketorolac, compazine, benadryl, and IVF didn't really help (pain still 8/10), I offered to give her small propofol doses and she agreed. The nurse was like "wat you wanna do? you push it" and I was happy to do so.

I looked up a protocol and gave 20 mg IVP q5 minutes up to 120 mg or until her HA went to 0. I ended up giving all 120 mg. She was monitored the entire time, never had a whiff of any problems from propofol. She fell asleep and snored but unfortunately her HA went down to 4/10. But she was happy we tried.

Not a resounding success but I'm willing to try it again. Only problem is I was in there for 30 minutes...
Anybody have success doing this?

I haven't used it myself, but it sounds interesting. Either way, I applaud you willingness to try new things that haven't quite become standard care yet. This is how we got a lot of the things we take for granted in EM these days. Before the trials, there is interest generating practice like this.



As for what I do, my usual approach is:

Acetaminophen 975 mg PO
Ketorolac 30 mg IV
Diphenhydramine 50 mg IV
Metoclopramide 10 mg IVPB
Magnesium 2g IV
Dexamethasone 10 mg IV
Normal saline 1000 ml IV

All of this at once. And then leave them alone in a dark room with a face mask for a couple of hours.

Sumatriptan if they don't have stroke risk factors or motor symptoms as part of their migraine.

VPA is also an effective option.

 

[Rekt]

Do you guys not talk to your nurses or do they hate you? I use LDK all the time. 0.3mg/kg over 10 minutes. My nurses love it because they know when I order it, it means it's time for the pt to GTFO my department. It either works or they hate the trip and want to leave. Win win.

Caveat being I reserve it typically only for the crazy malignerers or psychosomatization patients.

 

[turkeyjerky]

I do. Chlorpromazine is actually in our national therapeutic guidelines here in Australia if triptans fail. Works quite well.

Ahh. I always forget that you're down under.

I usually go for 10 mg prochlorperazine, 12.5 mg diphenhydramine, 15 mg of ketorlorac. Occaisionally add in dexamethasone if no DM and I think there's a risk for rebound, and magnesium if aura.

I would say at least 90% of people have near/complete relief w/ this. I usually recheck at 1 hr after administration and dc. I'll use VPA as 2nd line, but honestly I can't remember the last time that a patient didn't at least feel better and want to go home.

We're getting droperidol back soon and I'm looking forward to using it. Haven't used opiods for a headache basically ever, unless traumatic w/ a skull fracture.

 

[thegenius]

I do. Chlorpromazine is actually in our national therapeutic guidelines here in Australia if triptans fail. Works quite well.

I usually go for 10 mg prochlorperazine, 12.5 mg diphenhydramine, 15 mg of ketorlorac.

I wish the manufacturers would get together and rename these two drugs above:

chlor-pro
pro-chlor
-razine
-mazine

 

[RustedFox]

"You can't go to the prom with intractable hiccups."

Or something.

 

[lucid_leprechaun]

Ahh. I always forget that you're down under.

I usually go for 10 mg prochlorperazine, 12.5 mg diphenhydramine, 15 mg of ketorlorac. Occaisionally add in dexamethasone if no DM and I think there's a risk for rebound, and magnesium if aura.

I would say at least 90% of people have near/complete relief w/ this. I usually recheck at 1 hr after administration and dc. I'll use VPA as 2nd line, but honestly I can't remember the last time that a patient didn't at least feel better and want to go home.

We're getting droperidol back soon and I'm looking forward to using it. Haven't used opiods for a headache basically ever, unless traumatic w/ a skull fracture.

There was a recent study that showed Compazine > Thorazine

 

[WilcoWorld]

There was a recent study that showed Compazine > Thorazine

citation plz & thx

 

[Groove]

Ahh. I always forget that you're down under.

I usually go for 10 mg prochlorperazine, 12.5 mg diphenhydramine, 15 mg of ketorlorac. Occaisionally add in dexamethasone if no DM and I think there's a risk for rebound, and magnesium if aura.

I would say at least 90% of people have near/complete relief w/ this. I usually recheck at 1 hr after administration and dc. I'll use VPA as 2nd line, but honestly I can't remember the last time that a patient didn't at least feel better and want to go home.

We're getting droperidol back soon and I'm looking forward to using it. Haven't used opiods for a headache basically ever, unless traumatic w/ a skull fracture.

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.

 

[WildEMDoc]

The one time I did do propofol for a truly intractable migraine, it worked really well. Obviously picking the right patient is key, the person with a headache every day forever, requesting opiates is probably not the one to give this a go on.

This patient had failed reglan/benadryl/toradol, then a 2g Mg run, decadron, droperidol. Had an extensive history of migraines and an admission for ergotamine before.

Did sedation monitoring, a full 1mg/kg dose of propofol pushed. No complications, walked out of the ED about an hour later with 0/10 pain.

 

[WilcoWorld]

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.

 

[VA Hopeful Dr]

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.

Does it work quickly enough if given at the same time?

Honest question. I use mostly the same cocktail as most of you except IM since I'm outpatient.

 

[Groove]

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.

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...

 

[RustedFox]

ACDF surgery?

 

[Apollyon]

ACDF surgery?

Anterior Cervical Discectomy and Fusion.

 

[DoctorJDO]

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?