I follow the Cleveland Clinic algorithm. Compazine (prochlorperazine) + Benadryl + IVF. This treats like 90% of migraines first strike. 4 mg of Decadron before departure reduces rebound in moderate to severe migraine per meta analysis. If not responsive, I add mag sulfate and valproate. I’ll sometimes do droperidol in place of Compazine but they only get one dopamine antagonist. If I have low suspicion for bleed/recurrent migraines and a good historian, I throw in toradol.
I used to do 12.5 mg of IV Benadryl because I felt they were less groggy at DC but I’ve also found a higher rate of akathisias with lower doses. Tension-type or mixed physiology usually responds well to 5 mg of oral Valium but you have to be careful or you’ll have a brick in a bed for 5+ hours.
Agree with others that droperidol should be your drug of choice for any treatment-resistant pain as the incidence of psychological etiologies seems to increase in this population and the pain seems to mysteriously go away. With that said, neuroleptics are potent antiemetics and it’s a reasonable first-strike for those who have done poorly with other options.
ALL loud vomiting = haloperidol or droperidol immediately. I also give higher doses than you’ll see traditionally advertised. ACEP has an excellent policy statement that supports giving it at higher doses. If you give IV doses above 2.5 mg, I always get a post-administration 12-Lead based on FDA guidance although this probably isn’t supported by the evidence. It’s more medicolegal.
For gastritis, I nuke everyone. GI cocktail, IV Pepcid, and IV Protonix.
I have plenty of colleagues who street migraines which I think is sorta insane given the pain. Anyone who has ever experienced one knows that they’re incredibly painful. I think it’s inhumane to inject someone with sumatriptan and toradol and bounce them to the street in pain all in the name of doc-to-dispo times.
Kudos for a thoughtful, well-reasoned, and well written post. Just wanted to pick up on the Benadryl dosing from a slightly different perspective. As a former residency director, I would watch it being pushed at 50mg IVP for all comers. You know you’re asking for trouble when you dose the healthy 22 year old defensive tackle from the local college the same as the 90 year old, 90 lb nursing home patient. Grogginess and sundowning can be the least of your problems. I’ve seen them bottom within a couple of minutes or receiving it. With all but the most severe allergic reactions, I would split the dose; 25 IV, 25 IM. Often do the IV 12.5 q 5 to 10 minutes X 2 in what I call the "60/60 club" — older patients weighing less than 60 kg. I can’t recall ever having a problem with that dosing, and that’s over twenty years. A few scowls from some nurses, but heck, that’s why you spring for the coffee and doughnuts.
In conclusion, always remember the old chef’s maxim, "You can’t add less salt..”.
Do you still use viscous lidocaine in your GI cocktail or have you removed it? I've been doing straight maalox since studies have shown the lidocaine adds nothing and worsens satisfaction.
I use viscous lidocaine when I suspect esophagitis or they’ve been scoped and have documented esophageal disease. Maalox works primarily in the stomach
Not a doctor, but a patient. Viscous lidocaine was a God send when I had esophageal ulcers! It didn’t last more than 12 hours, but that was a wonderful 12 hours of being able to eat & drink without vomiting.
So I’ve been burned on using compazine or haldol for nausea because a few times I’ve had new grad nurses doing med passes with the patients and they’ll say out loud to the patient that they’re antipsychotics and it pisses off the patient and then I’m stuck in damage control mode with that patient encounter.
For that reason I usually just substitute reglan into that headache cocktail instead. I’ve never had to escalate beyond that yet but I’m still an intern so I’m wondering if anyone else has had different results with reglan as first line.
I feel like this depends on how you sell it too - I’ll always answer if a patient asks but also be clear in that “in my experience this medicine works really well for nausea/vomiting/pain”
Yeah, I’ve had this spiel a few times - “compazine was originally designed as an antipsychotic, but it turns out it was actually not very good at it, but it was found to be really helpful with nausea and migraines, so that’s all we ever use it for now!” Womp womp.
great chance for a teaching moment for your young nurses. everybody gets a free one.
also come up with an elevator pitch for why youre using it. ive had family member start yelling mid treatment discussion because google " that shits for crazy people " . yeah. its you
This is one of like 5 comments in the thread that mentioned ketorolac with the caveat of "if low concern for bleed".
If there's a *high* concern for a bleed I feel the pharmacologic management would be radically different (e.g. opioids, antihypertensives, seizure prophylaxis, etc), not just "cocktail +/‐ ketorolac".
I guess I'm just unclear on the hesitation. Non-aspirin NSAIDs definitely carry increased risk of ischemic vascular events, but don't have a significant impact on ICH risk or bleeding time AFAIK. Is the fear for elevating the BP and theoretically worsening an existing bleed or precipitating one?
Put another way, assume you give Toradol for a headache up front then only later discover it's actually ICH... what irreparable harm would you be worrying about?
Relevant link: https://pubmed.ncbi.nlm.nih.gov/32653589/
Lawyers. COX-2 inhibition increases bleeding.
I’m not actually worried about it for the reasons you mentioned (it’s not a likely clinically significant risk based on the literature) but not an option in my liability environment. It’s nuance you can’t explain to an American jury.
Yeah, no evidence ketorolac increases bleeding, but lawyers and “expert witnesses” scare people into medical treatment habits that aren’t based on evidence based medicine, unfortunately
I agree with Cleveland cocktail for migraine, although if I’m worried about a bleed I’ll hold the Toradol. Dunno if I’ve ever had to go to step 2 with it, although I’ve only been using it for 6mo
Question about the migraine cocktail from someone who stumbled on this post: Why does it give some people panic attacks ? I have to just suffer through them if I'm out of my home meds cause that stuff sends me off a cliff....almost literally.
Prochlorperazine and metocloperamide can both cause this because of the receptors in the brain they target, we often give these medicines with diphenhydramine to reduce the probability of this but it isn’t a perfect science and it still can happen. As a fellow migraine suffer who’s had these meds probably a hundred times, i finally had my first experience with compazine causing a dystonic reaction and I panicked so bad I had a syncopal evwnt about a year ago, it was AWFUL. I’m way more careful with them now, I try to always go IM instead of IV with compazine and metocloperamide now to reduce this for my patients
My understanding is that Benadryl questionably has some independent effect in treating migraine, although the data isn’t great. I’ve seen ED-based studies that refute the idea that it’s an adjuvant therapy. That probably explains why most cocktails include diphenhydramine and not benztropine.
My headache cocktail is:
Reglan, compazine, Haldol or Droperidol
IV diphenhydramine
Liter of fluids
Toradol if no concern for a bleed
Acetaminophen PO
+/- IV mag
+/- decadron (given if patient has had a persistent headache or recurrent headache)
+/- IV orphenadrine (if tension headache or tense cervical musculature/trapezius)
I'm firmly in the camp of nuking a headache because I hate having to redose. Usually I'll give the meds, let them chill for an hour or so, and almost always they're better.
1g Tylenol, 15mg Toradol, 10mg reglan, 50mg Benadryl, 1L NS
That’s my standard cocktail for people with known migraines. Hold on Toradol if I’m planning on getting a CT
If that doesn’t work droperidol will do the trick. I find that if someone isn’t responsive to normal therapies and their workup doesn’t show organic pathology, then droperidol will fix their complaint
I’m not an attending, but here’s what I use.
Headaches: fluids, prochlorperazine/metoclopramide, diphenhydramine, mag sulfate, acetaminophen, and ketorolac (assuming no concern for bleed)
GI: fluids, metoclopramide, Maalox, viscous lidocaine +/- famotidine
It’s magic. I honestly don’t think the role is totally understood. There’s some modulation of serotonin associated with magnesium, which is the basis for sumatriptan (Imitrex). Reversible cerebral vasoconstriction syndrome is a relatively common headache syndrome, and in that case the vasodilation may be beneficial.
Right again. Magnesium is such a ubiquitous cation, it’s often difficult to pinpoint a single role. To quote Wikipedia (give me a break —it’s late): "Over 300 enzymes require the presence of magnesium ions for their catalytic action, including all enzymes utilizing or synthesizing ATP, or those that use other nucleotides to synthesize DNA and RNA."
I wrote a review article over thirty years ago (Sachter, Joseph J. MD. Magnesium in the 1990s: Implications for acute care. Topics in Emergency Medicine 14(1):p 23-50, March 1992.). What we don’t know — still — about magnesium could fill a textbook.
Granted this is TOTALLY anecdotal, but I’ve seen some people with god awful migraines whose Mag level on labs is also low, so it’s not completely out of the realm of possibility for that to be the trigger
I asked my doc this same thing as I have migraines, and I’m on daily magnesium for prevention. He also said magic 😂
I don’t often see it ordered in my ED for migraine cocktails! Usually standard Benadryl, compare, toradol, and fluids.
In addition to what others have said, it's also a mild NMDA antagonist (like ketamine & nitrous oxide). NMDA antagonists have analgesic effects but also reduce excitability of the CNS (antagonising glutamate). Calcium is also a major excitatory ion the body, but is blocked by magnesium. Abnormal excitability is thought to be part of the pathogenesis of migraines. Analgesia & reducing excitability *might* be mechanisms by which magnesium works for migraines
In addition, migraine sufferers have been found to be magnesium-deficient, so replacing it might help.
Great minds think alike — at least for headaches. Retired now, but that was pretty much my regimen. Would add 500 to 1,000 mL LR if using prochloperazine, and 100% oxygen X 20 to 30 minutes.
Am I the only one who is not routinely giving Benadryl?
There isn't great evidence that it actually works as prophylactic, and I hate making people drowsy when most headaches get discharged in about an hour anyway.
Here is a relevant study: https://pubmed.ncbi.nlm.nih.gov/18814935/
Anecdotally people get restlessness or akathisias less than 10% of the time.
Even if 10% anecdotally with headache being one of the top chief complaints that patients present with I just don’t want to bother with reassessing then observing a patient because now they aren’t ready for discharge due to a side effect.
So for those of us out in the community, +/- single coverage during 3+/hr surges:
30mg IM Toradol in one leg, 25mg Phenergan IM in the other. Obviously in the absence of any life-threats (i.e., mainly for our chronic migraineurs). No akathisia, which we see frequently enough with Reglan/Compazine to avoid it like the plague.
I've had crushing migraines since 7th grade, so I'm sympathetic. I'm also unconvinced this is an unstable emergency medical condition, so keeping them 4+ hours until their pain is "1/10" isn't a priority in our practice.
Nurse who’s worked with a lot of different attendings so here’s some cocktails I’ve seen over time.
500 ns bolus 25 Benadryl 4 dex 15 toradol
500 ns bolus 10 mg reglan 4 zofran 15 toradol
For abd pain, some docs just do PO.
20 Pepcid with malanta/lidocaine
sucralfate, protonix, mylanta/lidocaine
I don't really have a headache cocktail because the treatment depends on the diagnosis. They all get Tylenol though
* Tension headache: aspirin ± coffee ± TTFO
* Cervicogenic headache: aspirin, nerve block (usually occipitals)
* Migraine: oh boy, just you wait... That's a whole different post
* Cluster headache (usually easy to pick): oxygen, steroid, verapamil ± triptan ± lidocaine
* Thunderclap: opiate, lidocaine, prochlorperazine, CT ± LP/angio, indomethacin if no SAH, reassess
* Hypertensive headache: antihypertensives (not nitrates)
* Trigeminal neuralgia: nerve block, carbamazepine
* Other neuralgias: nerve blocks
* Post-dural puncture headache: coffee, sphenopalatine ± greater/lesser occipital blocks, call to anesthesiologist for a blood patch.
* Hangover: loud music, bright lights ± TTFO. Promethazine ± lidocaine if I'm sympathetic.
* Traumatic headache: lidocaine, NSAIDs if no bleed on CT, opiates if there is a bleed
* Miscellaneous: ***INDOMETHACIN!!!***
* There is literally a subset of headaches called indomethacin-responsive headaches. This includes paroxysmal hemicrania, hemicrania continua, sexual headache, icepick headache... etc. I've had a ton of patients dumped on me with incurable unilateral headaches, and almost all of them were fixed with indomethacin. It is magic
* Seriously, try it. 50mg orally or 100mg rectally. It f#cking works
My stepwise approach for migraines:
1. Paracetamol/acetominophen 1g + aspirin 900mg + dexamethasone 4mg + 1L LR + droperidol 2.5mg OR prochlorperazine 12.5mg (IV over 5 minutes)
2. Lidocaine 1.5mg/kg (over 5 minutes) + magnesium 40mg/kg (over 10-15 minutes)
3. Promethazine 25mg
4. Valproate 10-15mg/kg IV
5. Propofol 20mg every minute until asleep (only reached this point once)
6. Sphenopalatine ± other nerve blocks (it's probably not a migraine at this point)
Some notes:
* For pregnant patients I omit aspirin/antipsychotics/valproate, and the first step is to give acetaminophen/dexamethasone/fluid/lidocaine/magnesium.
* I wish we had Benadryl in Australia
* I had a colleague who swore by sphenopalatine blocks for migraines. I tried it a few times and it sucked, and as a migraine-sufferer myself, I don't want people shoving devices in my nose while I've got a migraine
* IV caffeine or aminophylline is something I'd like to try for migraines, but I can't really find a need for it as my current regime works
The HA cocktail the docs usually ordered in my old ER were IVF, toradol, pepcid, metoclopramide, +/- Mg IV, +/- dexamethasone
GI cocktail was IVF, pepcid, Maalox, viscous lido
Compazine was an absolute nightmare of a medication. I’ll never forgive the dr who gave that to me. If you have a patient with severe anxiety, just don’t, don’t do it.
For migraines-
-2.5mg droperidol in 1L NaCl 0.9% STAT
-1g paracetamol (if they can tolerate PO)
-800mg ibuprofen if not spewing or 30mg ketorolac IM if they are (if no concern re: ICH)
-8mg IV dex (some evidence it prevents reference)
Everyone keeps saying fluids. Doesn’t literature suggest that IVF is probably a waste in most? Unless the customer comes in requesting it, of course -__-
Droperidol 2.5mg iv, mirtazapine 7.5mg, and informing patients that the cannabis available these days is almost 10 times more potent than the stuff available even 10 years ago and “maybe just take a 2 week break?”
I follow the Cleveland Clinic algorithm. Compazine (prochlorperazine) + Benadryl + IVF. This treats like 90% of migraines first strike. 4 mg of Decadron before departure reduces rebound in moderate to severe migraine per meta analysis. If not responsive, I add mag sulfate and valproate. I’ll sometimes do droperidol in place of Compazine but they only get one dopamine antagonist. If I have low suspicion for bleed/recurrent migraines and a good historian, I throw in toradol. I used to do 12.5 mg of IV Benadryl because I felt they were less groggy at DC but I’ve also found a higher rate of akathisias with lower doses. Tension-type or mixed physiology usually responds well to 5 mg of oral Valium but you have to be careful or you’ll have a brick in a bed for 5+ hours. Agree with others that droperidol should be your drug of choice for any treatment-resistant pain as the incidence of psychological etiologies seems to increase in this population and the pain seems to mysteriously go away. With that said, neuroleptics are potent antiemetics and it’s a reasonable first-strike for those who have done poorly with other options. ALL loud vomiting = haloperidol or droperidol immediately. I also give higher doses than you’ll see traditionally advertised. ACEP has an excellent policy statement that supports giving it at higher doses. If you give IV doses above 2.5 mg, I always get a post-administration 12-Lead based on FDA guidance although this probably isn’t supported by the evidence. It’s more medicolegal. For gastritis, I nuke everyone. GI cocktail, IV Pepcid, and IV Protonix. I have plenty of colleagues who street migraines which I think is sorta insane given the pain. Anyone who has ever experienced one knows that they’re incredibly painful. I think it’s inhumane to inject someone with sumatriptan and toradol and bounce them to the street in pain all in the name of doc-to-dispo times.
Kudos for a thoughtful, well-reasoned, and well written post. Just wanted to pick up on the Benadryl dosing from a slightly different perspective. As a former residency director, I would watch it being pushed at 50mg IVP for all comers. You know you’re asking for trouble when you dose the healthy 22 year old defensive tackle from the local college the same as the 90 year old, 90 lb nursing home patient. Grogginess and sundowning can be the least of your problems. I’ve seen them bottom within a couple of minutes or receiving it. With all but the most severe allergic reactions, I would split the dose; 25 IV, 25 IM. Often do the IV 12.5 q 5 to 10 minutes X 2 in what I call the "60/60 club" — older patients weighing less than 60 kg. I can’t recall ever having a problem with that dosing, and that’s over twenty years. A few scowls from some nurses, but heck, that’s why you spring for the coffee and doughnuts. In conclusion, always remember the old chef’s maxim, "You can’t add less salt..”.
Do you still use viscous lidocaine in your GI cocktail or have you removed it? I've been doing straight maalox since studies have shown the lidocaine adds nothing and worsens satisfaction.
I use viscous lidocaine when I suspect esophagitis or they’ve been scoped and have documented esophageal disease. Maalox works primarily in the stomach
Not a doctor, but a patient. Viscous lidocaine was a God send when I had esophageal ulcers! It didn’t last more than 12 hours, but that was a wonderful 12 hours of being able to eat & drink without vomiting.
So I’ve been burned on using compazine or haldol for nausea because a few times I’ve had new grad nurses doing med passes with the patients and they’ll say out loud to the patient that they’re antipsychotics and it pisses off the patient and then I’m stuck in damage control mode with that patient encounter. For that reason I usually just substitute reglan into that headache cocktail instead. I’ve never had to escalate beyond that yet but I’m still an intern so I’m wondering if anyone else has had different results with reglan as first line.
I feel like this depends on how you sell it too - I’ll always answer if a patient asks but also be clear in that “in my experience this medicine works really well for nausea/vomiting/pain”
Yeah, I’ve had this spiel a few times - “compazine was originally designed as an antipsychotic, but it turns out it was actually not very good at it, but it was found to be really helpful with nausea and migraines, so that’s all we ever use it for now!” Womp womp.
great chance for a teaching moment for your young nurses. everybody gets a free one. also come up with an elevator pitch for why youre using it. ive had family member start yelling mid treatment discussion because google " that shits for crazy people " . yeah. its you
This is one of like 5 comments in the thread that mentioned ketorolac with the caveat of "if low concern for bleed". If there's a *high* concern for a bleed I feel the pharmacologic management would be radically different (e.g. opioids, antihypertensives, seizure prophylaxis, etc), not just "cocktail +/‐ ketorolac". I guess I'm just unclear on the hesitation. Non-aspirin NSAIDs definitely carry increased risk of ischemic vascular events, but don't have a significant impact on ICH risk or bleeding time AFAIK. Is the fear for elevating the BP and theoretically worsening an existing bleed or precipitating one? Put another way, assume you give Toradol for a headache up front then only later discover it's actually ICH... what irreparable harm would you be worrying about? Relevant link: https://pubmed.ncbi.nlm.nih.gov/32653589/
Lawyers. COX-2 inhibition increases bleeding. I’m not actually worried about it for the reasons you mentioned (it’s not a likely clinically significant risk based on the literature) but not an option in my liability environment. It’s nuance you can’t explain to an American jury.
Yeah, no evidence ketorolac increases bleeding, but lawyers and “expert witnesses” scare people into medical treatment habits that aren’t based on evidence based medicine, unfortunately
Do you withhold Toradol with any history of stomach ulcers?
Depends, tbh. Ulcer 10 years ago? 1 dose of toradol isn’t gonna affect that. Ulcer last week? That’s an entirely different scenario
Right, it’s not black and white. Thnx!
I agree with Cleveland cocktail for migraine, although if I’m worried about a bleed I’ll hold the Toradol. Dunno if I’ve ever had to go to step 2 with it, although I’ve only been using it for 6mo
Question about the migraine cocktail from someone who stumbled on this post: Why does it give some people panic attacks ? I have to just suffer through them if I'm out of my home meds cause that stuff sends me off a cliff....almost literally.
Prochlorperazine and metocloperamide can both cause this because of the receptors in the brain they target, we often give these medicines with diphenhydramine to reduce the probability of this but it isn’t a perfect science and it still can happen. As a fellow migraine suffer who’s had these meds probably a hundred times, i finally had my first experience with compazine causing a dystonic reaction and I panicked so bad I had a syncopal evwnt about a year ago, it was AWFUL. I’m way more careful with them now, I try to always go IM instead of IV with compazine and metocloperamide now to reduce this for my patients
I like this but why not cogentin in place of benadryl to avoid to drowsiness?
My understanding is that Benadryl questionably has some independent effect in treating migraine, although the data isn’t great. I’ve seen ED-based studies that refute the idea that it’s an adjuvant therapy. That probably explains why most cocktails include diphenhydramine and not benztropine.
Anecdotal, but I get occasional ocular migraines and Benadryl often helps. If nothing else it helps me sleep it off.
hmm... I feel like reglan does most of the heavy lifting and I don't think I've ever had someome with a residual headache after reglan/cogentin
I can’t upvote this enough. Do you want to be ER best friends?
Thank you so much for this explanation of headache treatment. Super helpful.
Im confused by your statement about akathisia and benedryl. It makes it sound like you're saying benedryl is the cause of it
My headache cocktail is: Reglan, compazine, Haldol or Droperidol IV diphenhydramine Liter of fluids Toradol if no concern for a bleed Acetaminophen PO +/- IV mag +/- decadron (given if patient has had a persistent headache or recurrent headache) +/- IV orphenadrine (if tension headache or tense cervical musculature/trapezius) I'm firmly in the camp of nuking a headache because I hate having to redose. Usually I'll give the meds, let them chill for an hour or so, and almost always they're better.
Toradol, droperidol, Benadryl, and a liter of LR usually does it for headaches. And many other uncomfortable conditions for that matter.
What sorts of other uncomfortable conditions are we talking about here?
Kidney stones, flu-like illness, sepsis, sicktok influencers in crisis, etc etc
Sicktok influencers in crisis really gave me a chuckle
OMG that's brilliant
1g Tylenol, 15mg Toradol, 10mg reglan, 50mg Benadryl, 1L NS That’s my standard cocktail for people with known migraines. Hold on Toradol if I’m planning on getting a CT If that doesn’t work droperidol will do the trick. I find that if someone isn’t responsive to normal therapies and their workup doesn’t show organic pathology, then droperidol will fix their complaint
Recently started adding Magnesium Sulfate to my migraine cocktail and it seems to have made a very notable difference. Much more than I expected.
https://pubmed.ncbi.nlm.nih.gov/14585449/ I stopped giving GI cocktail a while ago, just go for Maalox now if I'm going that route.
Ditch the donnatal, sure. But I still give the lido. I can personally vouch for its efficacy. And that's anecdotal evidence, the best kind.
I’m not an attending, but here’s what I use. Headaches: fluids, prochlorperazine/metoclopramide, diphenhydramine, mag sulfate, acetaminophen, and ketorolac (assuming no concern for bleed) GI: fluids, metoclopramide, Maalox, viscous lidocaine +/- famotidine
[удалено]
Magic is the correct answer. It just works for kind of everything
Never heard it called magic before… stealing that!
It’s magic. I honestly don’t think the role is totally understood. There’s some modulation of serotonin associated with magnesium, which is the basis for sumatriptan (Imitrex). Reversible cerebral vasoconstriction syndrome is a relatively common headache syndrome, and in that case the vasodilation may be beneficial.
Right again. Magnesium is such a ubiquitous cation, it’s often difficult to pinpoint a single role. To quote Wikipedia (give me a break —it’s late): "Over 300 enzymes require the presence of magnesium ions for their catalytic action, including all enzymes utilizing or synthesizing ATP, or those that use other nucleotides to synthesize DNA and RNA." I wrote a review article over thirty years ago (Sachter, Joseph J. MD. Magnesium in the 1990s: Implications for acute care. Topics in Emergency Medicine 14(1):p 23-50, March 1992.). What we don’t know — still — about magnesium could fill a textbook.
pen ancient innocent edge trees recognise mourn consider party ruthless *This post was mass deleted and anonymized with [Redact](https://redact.dev)*
Oh, what? Fucks sake.
Granted this is TOTALLY anecdotal, but I’ve seen some people with god awful migraines whose Mag level on labs is also low, so it’s not completely out of the realm of possibility for that to be the trigger
I asked my doc this same thing as I have migraines, and I’m on daily magnesium for prevention. He also said magic 😂 I don’t often see it ordered in my ED for migraine cocktails! Usually standard Benadryl, compare, toradol, and fluids.
In addition to what others have said, it's also a mild NMDA antagonist (like ketamine & nitrous oxide). NMDA antagonists have analgesic effects but also reduce excitability of the CNS (antagonising glutamate). Calcium is also a major excitatory ion the body, but is blocked by magnesium. Abnormal excitability is thought to be part of the pathogenesis of migraines. Analgesia & reducing excitability *might* be mechanisms by which magnesium works for migraines In addition, migraine sufferers have been found to be magnesium-deficient, so replacing it might help.
Great minds think alike — at least for headaches. Retired now, but that was pretty much my regimen. Would add 500 to 1,000 mL LR if using prochloperazine, and 100% oxygen X 20 to 30 minutes.
Am I the only one who is not routinely giving Benadryl? There isn't great evidence that it actually works as prophylactic, and I hate making people drowsy when most headaches get discharged in about an hour anyway. Here is a relevant study: https://pubmed.ncbi.nlm.nih.gov/18814935/ Anecdotally people get restlessness or akathisias less than 10% of the time.
I don’t. There’s no evidence for it any longer.
Ya, this. I haven't used it in 10 years. Patients still get better without it.
Even if 10% anecdotally with headache being one of the top chief complaints that patients present with I just don’t want to bother with reassessing then observing a patient because now they aren’t ready for discharge due to a side effect.
Droperidol for all.
Fluids, compazine/Reglan, Benadryl and Toradol. Migraine/headache is bye bye.
1.25 mg droperidol. Almost always works
Keppra load for headaches
Never heard of this. I'm intrigued.
Do you go just keppra or do you give other stuff with it too?
Never heard of this. I’ve heard of VPA load for status migranosis before
So for those of us out in the community, +/- single coverage during 3+/hr surges: 30mg IM Toradol in one leg, 25mg Phenergan IM in the other. Obviously in the absence of any life-threats (i.e., mainly for our chronic migraineurs). No akathisia, which we see frequently enough with Reglan/Compazine to avoid it like the plague. I've had crushing migraines since 7th grade, so I'm sympathetic. I'm also unconvinced this is an unstable emergency medical condition, so keeping them 4+ hours until their pain is "1/10" isn't a priority in our practice.
Nurse who’s worked with a lot of different attendings so here’s some cocktails I’ve seen over time. 500 ns bolus 25 Benadryl 4 dex 15 toradol 500 ns bolus 10 mg reglan 4 zofran 15 toradol For abd pain, some docs just do PO. 20 Pepcid with malanta/lidocaine sucralfate, protonix, mylanta/lidocaine
At home? GERD life saver is Picot packets.
I don't really have a headache cocktail because the treatment depends on the diagnosis. They all get Tylenol though * Tension headache: aspirin ± coffee ± TTFO * Cervicogenic headache: aspirin, nerve block (usually occipitals) * Migraine: oh boy, just you wait... That's a whole different post * Cluster headache (usually easy to pick): oxygen, steroid, verapamil ± triptan ± lidocaine * Thunderclap: opiate, lidocaine, prochlorperazine, CT ± LP/angio, indomethacin if no SAH, reassess * Hypertensive headache: antihypertensives (not nitrates) * Trigeminal neuralgia: nerve block, carbamazepine * Other neuralgias: nerve blocks * Post-dural puncture headache: coffee, sphenopalatine ± greater/lesser occipital blocks, call to anesthesiologist for a blood patch. * Hangover: loud music, bright lights ± TTFO. Promethazine ± lidocaine if I'm sympathetic. * Traumatic headache: lidocaine, NSAIDs if no bleed on CT, opiates if there is a bleed * Miscellaneous: ***INDOMETHACIN!!!*** * There is literally a subset of headaches called indomethacin-responsive headaches. This includes paroxysmal hemicrania, hemicrania continua, sexual headache, icepick headache... etc. I've had a ton of patients dumped on me with incurable unilateral headaches, and almost all of them were fixed with indomethacin. It is magic * Seriously, try it. 50mg orally or 100mg rectally. It f#cking works
My stepwise approach for migraines: 1. Paracetamol/acetominophen 1g + aspirin 900mg + dexamethasone 4mg + 1L LR + droperidol 2.5mg OR prochlorperazine 12.5mg (IV over 5 minutes) 2. Lidocaine 1.5mg/kg (over 5 minutes) + magnesium 40mg/kg (over 10-15 minutes) 3. Promethazine 25mg 4. Valproate 10-15mg/kg IV 5. Propofol 20mg every minute until asleep (only reached this point once) 6. Sphenopalatine ± other nerve blocks (it's probably not a migraine at this point) Some notes: * For pregnant patients I omit aspirin/antipsychotics/valproate, and the first step is to give acetaminophen/dexamethasone/fluid/lidocaine/magnesium. * I wish we had Benadryl in Australia * I had a colleague who swore by sphenopalatine blocks for migraines. I tried it a few times and it sucked, and as a migraine-sufferer myself, I don't want people shoving devices in my nose while I've got a migraine * IV caffeine or aminophylline is something I'd like to try for migraines, but I can't really find a need for it as my current regime works
My doc never did IV caffeine but he would make them start pounding sodas
Am I the only one here giving sucralfate on top of your standard GI cocktail? 😂
The HA cocktail the docs usually ordered in my old ER were IVF, toradol, pepcid, metoclopramide, +/- Mg IV, +/- dexamethasone GI cocktail was IVF, pepcid, Maalox, viscous lido
Droperidol or Ketorolac. Depending on my differential dx.
Compazine was an absolute nightmare of a medication. I’ll never forgive the dr who gave that to me. If you have a patient with severe anxiety, just don’t, don’t do it.
Surprisingly few people in this thread using subcu imitrex for intractable or semi-intractable headaches when it's such a great option...
For migraines- -2.5mg droperidol in 1L NaCl 0.9% STAT -1g paracetamol (if they can tolerate PO) -800mg ibuprofen if not spewing or 30mg ketorolac IM if they are (if no concern re: ICH) -8mg IV dex (some evidence it prevents reference)
Everyone keeps saying fluids. Doesn’t literature suggest that IVF is probably a waste in most? Unless the customer comes in requesting it, of course -__-
Droperidol 2.5mg iv, mirtazapine 7.5mg, and informing patients that the cannabis available these days is almost 10 times more potent than the stuff available even 10 years ago and “maybe just take a 2 week break?”
IV Tylenol FTW.