08 October 2010

Friday Flashback - Small Victories

The triage note was not encouraging. "Migraine. History of same x 10 years. Workups included (-) CT, MRI scans. Has had daily migraine x four weeks. Pain not relieved with Imitrex today." A quick glance at the previous visit list revealed a number of ER evaluations for headaches, though not too many. He usually got dilaudid for his headaches.

"Migraines" suck the life force out of me. They are rarely in fact, migraines, but simply tension headaches versus undifferentiated headaches. The frequent headache patients usually require large doses of narcotics to "fix" and have strong affective components to them (I've cured a few migraines with ativan, an anti-anxiety medication which has no pain-relieving properties). There are many frequent headache patients who are simply seeking drugs. I try to avoid narcotic meds when possible, because of abuse potential, because they often provide only short-term relief, and because they can induce rebound headaches.

This guy seemed nice enough. He didn't present the dramatic emotional display that many faux-headaches show, and he was a somewhat unusual headache patient in that he was a) male and b) gainfully employed. I offered him the same initial treatment I do any other benign headache: toradol, a non-narcotic pain reliever, and some vistaril, an anti-nausea medicine. I braced myself for the inevitable objection: "That doesn't work for me" or "Oh, I just remembered, I'm allergic to toradol." But it didn't come. He had never heard of it, and apparently trusted me enough to give it a go. So I ordered the meds and went off to see the next patient in the queue.

Forty-five minutes later I dropped by his room to see how he was feeling. He was sitting up, with the lights on, rubbing the back of his neck with a look of amazement on his face. "Doc, I don't know what it was that you just gave me, but it was magic! I feel better than I have in weeks!" His wife wondered why no ER doc had ever given it to him before.

He went home happy and feeling well, and I went to see the next patient with a smile on my face. It's so nice when things work like they are supposed to...

Originally Posted 20 November 2007


  1. Introduce them to a Zomig/Zofran cocktail. I swear those two in combo are godlike for migraines.

  2. As a nurse and migraineur myself, I want to tear my hair out at docs for going to narcotics as a first line drug for headaches. Tordol works great and I used it for years before my beloved Imitrex came on the market.

    I remember one guy that came in 3 days in a row with his first migraine and we gave him Demerol IV (obviously a few years ago) Day 4 I said to the doc, obviously this ain't working, why don't we try compazine. After the compazine he said to me "wow, this is the first time the headache is actually gone, not just covered up."

    I am trying to get the docs I work with to tell patients flat at something simple like "I don't use narcotics to treat migraines." Just cut the argument off there. End of story. I think there can be exceptions, someone who usually gets relief from imitrex but can't use it for some reason, pregnant or whatever if her migraines are rare and she's barfing her toes up.

    Oh, but if we deny them their narcs the press-gainey's might go down. Can't let practicing good medicine get in the way of those press-gainey scores, can we?


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