Going to the emergency department is usually a challenging experience. This may be the worst place on earth for a person with migraine (apart from a death metal concert). Strong lights, noises, smells. Uncomfortable chairs. Long wait times. A migraine attack might not be a priority when people are there with broken bones and heart attacks. Still, it should be treated with empathy and appropriate care. But that’s not always the case

Severe attacks can force a person with migraine to go to the Emergency. Here are a few comments on this tough situation.

When should I consider going to the ED? 

There are two main reasons why you could consider going.

• You have a headache that’s different than usual, new symptoms, or you feel something is ‘not right’. Any person with migraine can have another problem leading to a different headache (sinusitis, aneurysm). A thunderclap headache (sudden onset to severe intensity) is a medical emergency. Any new neurologic symptom should be evaluated.
• Your attack is a typical migraine, but it won’t stop, you cannot function, you may have nausea and vomiting, and your stomach won’t keep anything. 

Attacks that last more than 72 hours are called Status Migrainosus (a fancy term to say “a state of migraine”). Some of these attacks can last a week and even more, especially if the person has Chronic Migraine  or there is a powerful trigger. 

What will they do for me there? 

First, the physician will evaluate you and check that there is no other cause for the severe headache. If tests are needed (including imaging), they can be done. 

Many treatments have been studied for migraine in the Emergency Room context. The advantage of the ER is to use IV (intravenous) medicines. Some medications used include:

• Hydration with IV fluids (water and salt to replenish your body fluid)
• Anti-emetics: Gravol, metoclopramide, prochloperazine, odansetron
• NSAIDs: ketorolac can be given IV
• Cortisone (dexamethasone) can be used, usually to prevent a recurrence
• DHE (dihydroergotamine)
• Opioids should be avoided but are still used too frequently

Some physicians in the ER can also do nerve blocks to treat the attack. Occipital nerve blocks may work for some people. 

If the situation is tough, a neurology consult can be required. 

Is there a way I can prepare to make things easier?

Being prepared is always a good idea. 

• Bring things to make your stay more comfortable: dark glasses, comfy clothes, ear plugs, snacks, a small pillow
• Prepare a list of your medical status, usual medications
• Get a plan from your treating physician to list medications that the ED doc could use

I had side effects with something they gave me. What can I do to avoid that in the future? 

Some medications used in the ER can cause side effects (and allergic reactions):

• Anti-emetics acting on dopamine: somnolence, restlessness, dystonic reactions (weird postures and spasms), low blood pressure
• DHE: muscle cramps, nausea, diarrhea, high blood pressure 
• Cortisone: restlessness, insomnia 
• Opioids: somnolence, constipation, muscle spasms (myoclonus, another fancy term)

Sometimes, drugs are given to make the person sleep, and somnolence can last for hours. Driving may not be safe when you leave the ER. Consider finding a safe way to get back home.

I was partially relieved but I still have a headache…can I get back to work tomorrow?

It is not unusual to have a lingering headache after an attack. The threshold for another attack may be lower. You may need a day or two of rest to avoid a recurrence (return of the attack). Different approaches can be used to avoid a recurrence, to be discussed with the physician.

Is there any way I can avoid going to the ED again? 

Overall, the goal should be to improve the control of your migraine situation. 

• Optimize your acute treatments (See this post)
• Identify major triggers and manage them 
• Consider a preventive treatment to decrease the severity of the attacks (See this post)

What if I have an aura and cannot talk? 

Some people with migraine have complex auras during which they can’t talk or even move (hemiplegic migraine) See this post. If this happens to you, consider the following options.

• Carry a bracelet with your aura diagnosis.
• Carry a document you could show to the ER doc.
• Be accompanied by someone who has a clear understanding of your medical problem.

** NEVER assume that a neurologic symptom (vision, sensation, speech, motion) is caused by a migraine attack, especially if it’s the first time it has happened to you. Any new symptom should be medically evaluated. 

My employer does not understand that my migraine attacks can be severe. I have been asked to go to the ER only to get a doctor’s note. I can usually manage at home. What can I do? 

Act like a Migraine Warrior. Get a note from your physician explaining that migraine can be severe and disabling. The World Health Organization recognizes that severe migraine attacks are as disabling as being quadriplegic. Your physician can review your situation and explain to the employer that asking for a useless ER visit is not the optimal way to make you feel better and is a poor use of health care resources.   

To read more: https://americanmigrainefoundation.org/resource-library/understanding-migraine-treatment-in-the-emergency-room/

REFERENCES

Orr SL, Aube M, Becker WJ, Davenport WJ, Dilli E, Dodick D, et al. Canadian Headache Society systematic review and recommendations on the treatment of migraine pain in emergency settings. Cephalalgia. 2014.

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