There are times when all your patient’s rescue strategies just are not working. The migraine episode is going on and on for several days, or it is worse than usual, or they are vomiting and getting dehydrated. Your patient has taken their usual rescue medications, perhaps done their usual thing when the rescue does not work (like a Medrol dose pack or a course of Depakote), and still the migraine rages on. They are calling you for guidance and at this point there is not much more to be done, except…………send them to the nearest appropriate Emergency Room or if you are lucky, a good Urgent Care. It is never a great option but sometimes you have to do it. Not many PCP offices have the option of putting in an IV and giving fluids and medications.
So when do you opt for this choice? Generally, I will send a patient for the next level of care when I know they need IV fluids for sure, another route for their medications, and everything else has not worked well.
I know that among adult migraineurs, going to the ED often involves dealing with staff thinking they are ‘just there for the drugs”, which is just so unfortunate and discriminatory. I don’t hear that from our pediatric families, they are not usually having that experience. That doesn’t mean that the ED visit is great, but at least they are not hearing that. I am sure that some do run into the drug seeking label but it is not at the level experienced by adult patients.
If your patient wants to go to the ED/UC or you feel they need to, there are a few things to consider.
First, it is really important to know they can receive IV medications and fluids. Imagine going to a facility, being exposed to lights and noise and smells when you have a terrible migraine, being exposed to infectious illnesses, waiting around forever, and then being given a naproxen, ondansetron, and a Gatorade. So disheartening! When I hear this, the next thing I hear is, I already did that at home, what a waste of time! Not to mention the copay.
Second, you need to make sure the site is comfortable taking care of a teen with migraine- many facilities will turn them away if the patient is not an adult.
Third, try not to go during peak hours, such as after school through the early evening or other particularly busy times. You are guaranteed to wait and wait and wait……… They can call ahead to check.
Fourth, the family should bring a list of their allergies, usual medications, their rescue medications, and anything else they have done recently such as steroids, depakote, injections, Nerivio device, etc. Also when they last took the medications. Planning ahead also helps. Makes no sense to take a dose of naproxen and a triptan and then go to the ED. The ED care will be limited by that, not be able to give medications IV that could help. This again leads to another failed effort and large copay.
An even better strategy is to bring a list or even a letter from their provider about what usually works for them specifically in these cases. For example: ketorolac/toradol IV, 1-2 bags of IV fluids, zofran IV and a dose of IV decadron helps me. I react badly to IV compazine, benadryl and reglan but they help if given by mouth. A dose of depakote IV is helpful. Also, an extra bag of IV fluids is always helpful and keeps me from coming back.
Where should they go for the “Migraine Cocktail”? Hopefully you as their provider can guide them to the best and most appropriate facility for assistance. Which EDs are likely to be helpful, and you can call in to the facility to let them know to expect them, what is going on, and what you hope they can receive. Many pediatric patients end up in the ED, as the local urgent care facilities do not treat kids, at least do not do the IV medications.
There are lots of urgent care centers around too. I try to know which ones are most appropriate and give the care that is needed. I often rely on my patients to let me know about their experiences, good and bad. I keep a list of those centers in the area to steer the patients. You can call ahead too. I encourage patients to call around as well and ask specifically, do you give IV fluids and medications to kids and teens? Again, if the child or teen is vomiting, their migraine will likely not resolve without IV fluids and medications. You want them to get the care they need, feel better, and not have a huge unnecessary financial burden.
Some pediatric headache centers or large hospitals with infusion centers can sometimes offer the migraine cocktail experience as well. It is helpful to know how to access these centers, hours of operations, etc. It can be a godsend for pediatric patients.
What about being admitted to the hospital for intractable migraine? There are few reasons for admission, in my opinion: if there are real concerns about mental status, changes in an MRI, other clinical red flags; if the vomiting is intractable; or if the next step is a course of IV DHE (dihydroergotamine), a decision to be made by a headache specialist or neurologist. Being admitted for a migraine patient is usually an difficult experience. They are in a room with a roommate, sleep is disrupted, family is disrupted, not getting the rest they need, etc.
DHE can be very useful in cases of status migrainosus/intractable migraine, but requires medications and monitoring for both drug effects and significant side effects. If DHE is needed, some headache clinics or infusion centers have started to offer outpatient DHE over the course of 2-3 days, which has been shown to be better tolerated, successful at breaking the migraine, and less disruptive to family life and functioning. Again, the decision for this course of treatment is determined by a headache specialist or neurologist.
One thing I tell my families is that at some point in life of just about every person with migraine ends up in the ED. They can go through life with their own typical migraine pattern 99% of the time, with a rescue plan that works well for them. And then there is that one time when there is a combination of triggers and environmental stressors that results in a whopper of a migraine. The usual treatments are not effective, and they need a higher level of care. It is not a failure in their rescue treatment but just a more severe than usual migraine that needs more care than they can do at home.
HeadFirst PNP 