Lumbar Puncture on an Anticoagulated Patient in the Emergency Department: Is it safe?

lumbar punctureThe lumbar puncture (LP) procedure is commonly performed in the Emergency Department (ED). While minor complications of LP such as post-procedure headache or back pain occur somewhat regularly, significant complications such as post-procedural spinal hematomas, are rare.1 Despite their low incidence, these spinal hematomas are associated with a significant amount of morbidity for the patient and increased medicolegal risk for the provider.

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Managing migraine headaches in complicated patients

migraineCase Vignette

A 42-year-old female presents at 10 pm with a throbbing right frontal headache associated with nausea, vomiting, photophobia, and phonophobia. The headache is severe, rated as “10” on a 0 to 10 triage pain scale. The headache began gradually while the patient was at work at 2 pm. Since 2 pm, she has taken 2 tablets of naproxen 500 mg and 2 tablets of sumatriptan 100 mg without relief.

The patient has a diagnosis of migraine without aura. She reports 12 attacks per month. The headache is similar to her previous migraine headaches. She is forced to present to an Emergency Department (ED) on average 2 times per month for management of migraine refractory to oral therapy. She reports a history of dystonic reactions and akathisia after receiving IV dopamine antagonists during a previous ED visit. The physical exam is non-contributory including a normal neurological exam, normal visual fields and fundoscopic exam, and no signs of a head or face infection. When you are done evaluating her, the patient reports that she usually gets relief with 3 doses of hydromorphone 2 mg + diphenhydramine 50 mg IM, and asks that you administer her usual treatment. What do you do?

Background

Migraine is a neurological disorder characterized by recurrent painful headaches and abnormal processing of sensory input resulting in symptoms such as photophobia, phonophobia, and osmophobia.1 Central to disease pathogenesis is abnormal activation of nociceptive pathways.2 Disease severity ranges from mild to severe. Patients at one end of the spectrum have rare episodic headaches. On the other end are patients who have headaches on more days than not, patients who are functionally impaired by their headaches, and patients who frequently cannot participate fully in work or social activities. Chronic migraine, a sub-type of migraine defined by ≥15 days with headache for at least 3 consecutive months, is experienced by 1-3% of the general population.3

ED use for treatment of migraine is common. 1.2 million patients present to U.S. ED’s annually for management of this primary headache disorder.4 Parenteral opioids are used to treat the acute headache in slightly more than 50% of all ED visits.4 Multiple authorities have cautioned against the use of opioids for migraine.5,6 However, the frequent use of opioids has continued unabated, despite the publication in the EM, neurology, and headache literature of dozens of randomized controlled trials (RCTs) demonstrating safety and efficacy of parenteral alternatives, most notably dopamine antagonists and non-steroidal anti-inflammatory drugs.7

Opioids have been associated with a variety of poor outcomes in migraine patients including:

  1. Progression of the underlying migraine disorder from episodic to chronic migraine8
  2. Increased frequency of return visits to ED9
  3. Less responsiveness to subsequent treatment with triptans10
  4. Less frequent headache relief than patients who received dihydroergotamine or dopamine antagonists11

In contrast, a high quality, ED-based RCT did not demonstrate more harm from 1 or 2 doses of meperidine than from dihydroergotamine.12 Hydromorphone, the parenteral opioid currently used most commonly in U.S. EDs,4 has never been studied experimentally in migraine patients. However, given the wide range of parenteral alternatives, the possibility that opioids may worsen the underlying migraine disorder, and the fact that they are less efficacious than other treatments, opioids should not be offered as first- or second-line therapy for patients who present de novo to an ED with an acute migraine (assuming no contraindications to alternative medications).

Questions:

1) Other than opioids, what parenteral therapies can be offered to this patient?

The 3 classes of parenteral therapeutics with the most evidence supporting safety and efficacy for use as first-line therapy for migraine are the following13:

  1. Dopamine antagonists
  2. NSAIDs
  3. Subcutaneous sumatriptan

However, this patient has relative contraindications to each of these. Other parenteral medications used for migraine are listed in the following table.

Table: Alternative parenteral migraine therapies

Agent Dose Adverse events Evidence supporting efficacy Notes
Acetaminophen (APAP)14,15 1 gm IV Well tolerated In one trial, IV APAP did no better than placebo. In another, IV APAP was comparable to an IV NSAID.
Dihydroergotamine16 0.5 mg -1 mg IV infusion Nausea is common. Pre-treat with anti-emetics. In one trial, DHE was less effective than sumatriptan at 2 hours but more effective by 4 and 24 hours. Use cautiously in patients with cardiovascular risk factors.
Ketamine17 0.08 mg/kg SC Fatigue, delirium In one low quality cross-over RCT, ketamine outperformed placebo.
Magnesium18–21 1-2 gm IV Flushing In RCTs of varying quality, IV mg did not consistently outperform placebo Efficacy data is most compelling for migraine with aura.
Octreotide22 0.1 mg SC Diarrhea, injection site reactions In a high quality RCT, octreotide did not outperform placebo
Propofol23,24 10 mg IV every 10 minutes as needed up to 80 mg Or 30-40 mg IV with 10-20 mg bolus every 3-5 minutes up to 120 mg Sedation, hypoxia In a low quality RCT, propofol outperformed dexamethasone. In another low quality trial, propofol outperformed sumatriptan. It is not clear whether the migraine returns after propofol administration has been completed. Previous ALiEM post on migraines and propofol.
Valproic acid28,29 1000 mg IV Well tolerated In a high quality RCT, valproate was outperformed by metoclopramide and ketorolac. In a lower quality RCT, valproate was comparable to IV aspirin.
APAP= acetaminophen; DHE= dihydroergotamine; Mg= magnesium

In some patients, greater occipital nerve blocks with a long-acting local anesthetic such as bupivaciane may play a role.25 While the above alternative parenteral therapies may benefit this patient, available evidence regarding risks and benefits does not dictate that these other therapies must be offered prior to use of opioids.

2) Does the fact that this patient makes frequent use of the ED indicate an unmet medical need?

As with congestive heart failure and asthma, frequent use of an ED for migraine is associated with worse underlying disease.26 These frequent users are more likely to have chronic migraines (> 15 headache days per month) and psychiatric co-morbidities.26 Concomitant medication overuse headache, a disorder defined by an upward spiral of increasing headache frequency in the setting of increased usage of analgesic or migraine medication, is also common.27 Management of complicated patients with migraines is exceedingly difficult, particularly during a busy ED shift, and may lead to frustration for both the healthcare practitioner and the patient. Ideally, outpatient healthcare practitioners with appropriate expertise should direct management of complicated patients with migraines.

3) Should the patient be administered 3 doses of hydromorphone 2 mg + diphenhydramine 50 mg IM as she wishes?

Management of chronic pain patients can be trying and demoralizing for emergency physicians because the underlying problem cannot be solved, and all avenues of treatment are flawed.  Allowing the patient to suffer without appropriate justification is cruel. Delaying opioid administration during good faith efforts to identify alternative effective therapeutic agents is reasonable. Withholding opioids on principle is problematic because for most patients in most circumstances, published data do not establish that the benefit of pain relief is outweighed by the potential for opioid induced harm. On the other hand, thoughtlessly acquiescing to repeated requests for opioids during multiple ED visits is a violation of good medical practice, because of the concern of exacerbating the underlying migraine disorder, which could result in more ED visits, increased number of headache days, and the potential to cause refractoriness to standard migraine medication. One might compare it to administering antibiotics for bronchitis.

Case Resolution

The best solution for the patient in the case vignette is to administer parenteral opioids only as rescue therapy for patients who adhere to an established outpatient plan of care. Acutely, the patient should not be allowed to suffer. However distasteful it may be, the harm arising from 3 isolated doses of parenteral opioids during one ED visit is unlikely to be either long-lasting or severe. But a prerequisite to treatment with opioids during a subsequent visit should be adherence to appropriate outpatient treatment: specifically, patients who require parenteral opioids for migraines should regularly attend outpatient appointments with an appropriate healthcare provider within the ED’s healthcare system.

Department-wide opioid policies are essential, as physician to physician variability in care may undermine a strict approach to opioids. Ideally, a committee with relevant expertise can monitor frequently presenting pain patients and develop patient-specific interventions that will be enforced by all practitioners during subsequent visits. If need be, the terms of treatment can be reinforced with a written document (example in the Appendix). This written document is not meant to be legally binding, but should be used to establish expectations. The last thing a busy emergency physician needs is a battle over opioids with a frequently presenting migraine patient. But before discharge, there should be a conversation about expectations during future ED visits. This will contribute to increased satisfaction for both the provider and the patient.

Top image: (c) Can Stock Photo

Migraine and opioids

A written understanding between the staff of the emergency department and ______.

As providers of emergency healthcare 24 hours per day, seven days per week, we take enormous pride in our ability to provide top-notch care. We save lives, treat pain and illness, and work hard to ensure the best possible health for all of our patients. We are asking you to sign this agreement because we believe that together, you and we can do a better job of managing your headaches.

You have a migraine. A migraine is a chronic headache disorder. For reasons that are still unclear to scientists, the brains of patients with migraines experience pain differently than people without migraine. The result of this is horrible headaches and other symptoms like nausea, vomiting, sensitivity to light and sound, and dizziness. There are effective treatments for migraines. Some patients with migraines take medications every day to prevent headaches from even beginning. Some patients with migraine receive injections to decrease the number of headaches they experience. Some patients learn techniques to take control of the pain once it begins.

We have noticed that because of your headaches, you have to come to the emergency department (ED) to get treatment frequently. When you come to the ED, the only medication that helps your headache is an opioid medication. Examples of opioid medications include: hydromorphone (Dilaudid), meperidine (Demerol), morphine, butorphanol, oxycodone (Percocet, Oxycontin). We want to work with you to decrease the number of times that you have to come to the ED to get treatment for migraine. Based on published scientific studies, we think that treating migraines with opioid medications may be worsening your migraines. We understand that opioid medications make you feel better quickly, but ultimately, they may be doing more harm than good. Therefore, we want to limit the number of doses of opioids that you receive in the ED. With that goal in mind, we are going to require the following prior to giving you opioid injections in the ED.

  • You need to establish a relationship with a doctor who can help you manage your migraines. The names and contact numbers of some doctors we recommend are listed below. You may use your own doctor, but the doctor must be experienced in the management of headache or pain, must be local, and must be willing to be available by telephone whenever you are in the ED
  • Every ED visit must be followed up with a visit to that doctor
  • You need to make a good faith effort to reduce the number of times you visit the ED for your treatment of migraines.

References

1.
Headache C. The International Classification of Headache Disorders, 3rd edition (beta version). Cephalalgia. 2013;33(9):629-808. [PubMed]
2.
Goadsby P. Pathophysiology of migraine. Ann Indian Acad Neurol. 2012;15(Suppl 1):S15-22. [PubMed]
3.
Lipton R. Chronic migraine, classification, differential diagnosis, and epidemiology. Headache. 2011;51 Suppl 2:77-83. [PubMed]
4.
Friedman B, West J, Vinson D, Minen M, Restivo A, Gallagher E. Current management of migraine in US emergency departments: an analysis of the National Hospital Ambulatory Medical Care Survey. Cephalalgia. 2015;35(4):301-309. [PubMed]
5.
Langer-Gould A, Anderson W, Armstrong M, et al. The American Academy of Neurology’s top five choosing wisely recommendations. Neurology. 2013;81(11):1004-1011. [PubMed]
6.
Loder E, Weizenbaum E, Frishberg B, Silberstein S, American H. Choosing wisely in headache medicine: the American Headache Society’s list of five things physicians and patients should question. Headache. 2013;53(10):1651-1659. [PubMed]
7.
Sumamo S, Dryden D, Pasichnyk D, et al. Acute Migraine Treatment in Emergency Settings. November 2012. http://www.ncbi.nlm.nih.gov/books/NBK115368/. [PubMed]
8.
Bigal M, Serrano D, Buse D, Scher A, Stewart W, Lipton R. Acute migraine medications and evolution from episodic to chronic migraine: a longitudinal population-based study. Headache. 2008;48(8):1157-1168. [PubMed]
9.
Colman I, Rothney A, Wright S, Zilkalns B, Rowe B. Use of narcotic analgesics in the emergency department treatment of migraine headache. Neurology. 2004;62(10):1695-1700. [PubMed]
10.
Burstein R, Collins B, Jakubowski M. Defeating migraine pain with triptans: a race against the development of cutaneous allodynia. Ann Neurol. 2004;55(1):19-26. [PubMed]
11.
Friedman B, Kapoor A, Friedman M, Hochberg M, Rowe B. The relative efficacy of meperidine for the treatment of acute migraine: a meta-analysis of randomized controlled trials. Ann Emerg Med. 2008;52(6):705-713. [PubMed]
12.
Carleton S, Shesser R, Pietrzak M, et al. Double-blind, multicenter trial to compare the efficacy of intramuscular dihydroergotamine plus hydroxyzine versus intramuscular meperidine plus hydroxyzine for the emergency department treatment of acute migraine headache. Ann Emerg Med. 1998;32(2):129-138. [PubMed]
13.
Orr S, Aubé M, Becker W, et al. Canadian Headache Society systematic review and recommendations on the treatment of migraine pain in emergency settings. Cephalalgia. 2015;35(3):271-284. [PubMed]
14.
Turkcuer I, Serinken M, Eken C, et al. Intravenous paracetamol versus dexketoprofen in acute migraine attack in the emergency department: a randomised clinical trial. Emerg Med J. 2014;31(3):182-185. [PubMed]
15.
Leinisch E, Evers S, Kaempfe N, et al. Evaluation of the efficacy of intravenous acetaminophen in the treatment of acute migraine attacks: a double-blind, placebo-controlled parallel group multicenter study. Pain. 2005;117(3):396-400. [PubMed]
16.
Winner P, Ricalde O, Le F, Saper J, Margul B. A double-blind study of subcutaneous dihydroergotamine vs subcutaneous sumatriptan in the treatment of acute migraine. Arch Neurol. 1996;53(2):180-184. [PubMed]
17.
Nicolodi M, Sicuteri F. Exploration of NMDA receptors in migraine: therapeutic and theoretic implications. Int J Clin Pharmacol Res. 1995;15(5-6):181-189. [PubMed]
18.
Corbo J, Esses D, Bijur P, Iannaccone R, Gallagher E. Randomized clinical trial of intravenous magnesium sulfate as an adjunctive medication for emergency department treatment of migraine headache. Ann Emerg Med. 2001;38(6):621-627. [PubMed]
19.
Shahrami A, Assarzadegan F, Hatamabadi H, Asgarzadeh M, Sarehbandi B, Asgarzadeh S. Comparison of therapeutic effects of magnesium sulfate vs. dexamethasone/metoclopramide on alleviating acute migraine headache. J Emerg Med. 2015;48(1):69-76. [PubMed]
20.
Cete Y, Dora B, Ertan C, Ozdemir C, Oktay C. A randomized prospective placebo-controlled study of intravenous magnesium sulphate vs. metoclopramide in the management of acute migraine attacks in the Emergency Department. Cephalalgia. 2005;25(3):199-204. [PubMed]
21.
Bigal M, Bordini C, Tepper S, Speciali J. Intravenous magnesium sulphate in the acute treatment of migraine without aura and migraine with aura. A randomized, double-blind, placebo-controlled study. Cephalalgia. 2002;22(5):345-353. [PubMed]
22.
Levy M, Matharu M, Bhola R, Meeran K, Goadsby P. Octreotide is not effective in the acute treatment of migraine. Cephalalgia. 2005;25(1):48-55. [PubMed]
23.
Soleimanpour H, Taheraghdam A, Ghafouri R, Taghizadieh A, Marjany K, Soleimanpour M. Improvement of refractory migraine headache by propofol: case series. Int J Emerg Med. 2012;5(1):19. [PubMed]
24.
Moshtaghion H, Heiranizadeh N, Rahimdel A, Esmaeili A, Hashemian H, Hekmatimoghaddam S. The Efficacy of Propofol vs. Subcutaneous Sumatriptan for Treatment of Acute Migraine Headaches in the Emergency Department: A Double-Blinded Clinical Trial. Pain Pract. 2015;15(8):701-705. [PubMed]
25.
Voigt C, Murphy M. Occipital nerve blocks in the treatment of headaches: safety and efficacy. J Emerg Med. 2015;48(1):115-129. [PubMed]
26.
Friedman B, Serrano D, Reed M, Diamond M, Lipton R. Use of the emergency department for severe headache. A population-based study. Headache. 2009;49(1):21-30. [PubMed]
27.
Kristoffersen E, Lundqvist C. Medication-overuse headache: epidemiology, diagnosis and treatment. Ther Adv Drug Saf. 2014;5(2):87-99. [PubMed]
28.
Leniger T, Pageler L, Stude P, Diener H, Limmroth V. Comparison of intravenous valproate with intravenous lysine-acetylsalicylic acid in acute migraine attacks. Headache. 2005;45(1):42-46. [PubMed]
29.
Friedman B, Garber L, Yoon A, et al. Randomized trial of IV valproate vs metoclopramide vs ketorolac for acute migraine. Neurology. 2014;82(11):976-983. [PubMed]
2019-04-28T21:14:07-07:00

AIR Series: Neurology Module 2 – Headaches, Seizures, and Other

Welcome to the Second Neurology Module! After carefully reviewing all relevant posts from the top 50 sites of the Social Media Index the ALiEM AIR Team is proud to present the highest quality neurology content relating to headaches, seizures, and other neurologic emergencies. Below we have listed our selection of the 17 highest quality blog posts within the past 12 months (as of December 2015) related to neurologic emergencies, curated and approved for residency training by the AIR Series Board. More specifically in this module, we identified 9 AIRs and 8 Honorable Mentions.

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AIR Series: Neurology Module 1 – Bleeds and Strokes

Welcome to the first Neurology Module! After carefully reviewing all relevant posts from the top 50 sites of the Social Media Index the ALiEM AIR Team is proud to present the highest quality neurology content relating to intracranial hemorrhage and stokes. Below we have listed our selection of the 17 highest quality blog posts within the past 12 months (as of November 2015) related to neurologic emergencies, curated and approved for residency training by the AIR Series Board. More specifically in this module, we identified 5 AIRs and 12 Honorable Mentions.

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PEM Pearls: Migraine Treatment for Pediatric EM Patients

migraine treatment for pediatric em patients © Can Stock Photo / SergiyNYou are working your evening shift at the pediatrics emergency department, and you walk into a darkened patient room with a distressed mother and her otherwise healthy 10-year old son who is curled in a ball, holding his head and crying. Her mother tells you that the around-the-clock ibuprofen has barely touched his 2-day headache.

After determining that your patient has no neurologic deficits and that this is most likely a primary headache, what can you do to break his symptoms?

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Assessing and Managing Delirium in Older Adults

© Can Stock Photo / focalpoint delirium in older adultsEvery day in the Emergency Department we see older adults with dementia who have developed delirium and are brought in because of worsening agitation, combativeness, or confusion. In order to care for them, we have to consider what the underlying cause of their agitation may be, but we also have to protect the patient and staff in case of violent outbursts. Older adults experience a phenomenon termed ‘homeostenosis’ in which their physiologic reserve and the degree to which they can compensate for stressors is narrowed, putting them at risk for delirium. This post will outline ways to prevent and de-escalate agitation in a patient with delirium, and how to treat it pharmacologically in a cautious manner to minimize side effects.

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2018-10-28T21:23:40-07:00

Ketamine for Excited Delirium Syndrome

Delirium canstockphoto11866731Excited delirium syndrome is defined as “a syndrome of uncertain etiology characterized by delirium, agitation, and hyperadrenergic autonomic dysfunction”.1 You may have encountered a patient like this in the ED or prehospital setting. Although the etiology is impossible to determine in many cases, stimulant abuse and other drugs are involved in a majority of cases. An 8% mortality has been ascribed to Excited Delirium Syndrome, resulting from hyperthermia, severe metabolic acidosis, and cardiovascular collapse.

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