![]() ![]() But never push IV Benadryl – it gets you high. That being said, I pick my battles and I don’t knock it our of nurses hands or reprimand the residents every time or even fight with patients if they really think it helps. I’ve heard people suggest diphenhydramine works by knocking out the patient and as any migraine sufferer knows, the best treatment is probably sleep, but the evidence suggests that diphenhydramine just doesn’t add much. If the patient gets akathisia, then I give midaz. Midazolam has some effect for prophylaxis, but the rate of akathisia is low enough that I don’t think it’s worth the risks (or extending LOS due to zonking out the patient). ĭiphenhydramine doesn’t prevent metoclopramide-associated akathisia (which in my experience, is much less common than the literature describes). I don’t give them to everyone, but for patients who get headaches in groups, have been having headaches for a while, or are just miserable enough, I give 10mg of dexamethasone.ĭiphenhydramine doesn’t work for headaches. Steroids don’t fix the headache today but they decrease recurrence in some patients. I make sure the patient is up to their appropriate daily dosing of acetaminophen or ibuprofen with appropriate consideration of contraindications, they might make a difference so why not? PO ibuprofen is likely as effective as ketorolac, and getting a shot doesn’t seem to have a placebo effect (if nothing else, this study is worth reading for the amazing design summarized in an accompanying editorial on placebos ). IM works fine if the patient doesn’t have an IV – most headache patients don’t need labs or IV fluids so no reason to start one routinely and a lot of even severe headaches are suitable for fast track. ![]() No reason to wait.Īny of the dopaminergic antiemetics are effective I generally use whichever is typically used in my ED (and doesn’t have to come from pharmacy). I usually turn off the lights as soon as I walk in. Second: Symptom managementĮven migraines without frank photophobia often feel better in a darker room. Patients come to see us for our expertise and often find it reassuring that we’ve listened and examined them and aren’t concerned. Of course, none of these questions are black and white and there’s a lot of room for clinical judgment one minor deviation from typical headache does not mandate imaging. I’ve gotten myself in trouble by asking up front if it’s the same as usual or “worst headache of your life” – even if they don’t mean to, patients sometimes seem like they are trying to validate why they came to the ED (to us or to themselves). “it’s usually on that side and you’re nauseated when you get a headache like this…?”). Is the headache similar to their prior headaches in character, location, magnitude, timing, associated symptoms? Are there concerning features (exertional, vomiting, personal or family history of aneurysms)? Was it maximal at onset (or sudden/severe)? I find it helpful to ask: “what were you doing when it started?” “how bad was it when it started?” “when was it the worst?” and only after listening for a while, I backdoor into whether it is typical for them (e.g. My general approach to headaches: First: Is there a dangerous cause? ![]() Our approach to headaches has matured in recent years, largely because of a bunch of great studies by Ben Friedman’s group at Montefiore (COI: his brother and I were residency classmates) see Headache guidelines (he’s the first et al in the Orr paper cited above, REF) his Annals Expert Clinical Management paper and his FOAM post at ALiEM. Thanks for this great overview over ED headache management. ![]()
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