Teaching LGBTQ+ Health: 10 Clinical Pearls

lgbtq+ health teaching course

Are you confident in your skills when taking care of LGBTQ+ patients? Are you able to teach principles of LGBTQ+ health to trainees in your clinical practice and the classroom setting? Learners across the health professions demand improved LGBTQ+ health content and additional training opportunities in their schools’ curricula. However, most clinician educators received little, if any, training in LGBTQ+ health when they were students.

10 Clinical Pearls on Teaching About LGBTQ+ Health

The following are some sneak-peak clinical pearls from the Teaching LGBTQ+ Health online course that just launched. This open access, interactive, CME course was published in conjunction with National LGBT Health Awareness Week (March 22-26, 2021). It was developed by Stanford Medicine and designed by Dr. Michael Gisondi (Stanford Emergency Medicine), Timothy Keyes (Stanford SOM), Shana Zucker (Tulane SOM), and Deila Bumgardner (Stanford EdTech) in collaboration with the Medical Student Pride Alliance

  1. LGTBQ+ health encompasses so much more than the historical, one-dimensional portrayals of gay men previously used to teach about HIV/AIDS.
  2. Treat your LGBTQ+ patients with dignity and respect by correctly using LGBTQ+ health vocabulary. 
  3. Language is both fluid and deeply personal—not all LGBTQ+ patients refer to themselves with similar terms, and the ways in which these terms are used may change over time.
  4. Sex, gender, and sexual orientation are related but distinct concepts. 
  5. Intersecting minority statuses have a synergistic effect on the health and health-seeking behaviors of LGBTQ+ patients.
  6. The CDC recommends the use of ‘The 5 P’s of Sexual Health’ framework for obtaining a sexual history.
  7. In accordance with the PARTNER2 study, ‘undetectable = untransmittable.’
  8. Compliance with PrEP (pre exposure prophylaxis) for HIV reduces the risk of acquiring HIV by approximately 99%.
  9. Transmasculine patients seek routine primary care and Pap testing less frequently than cisgender patients.
  10. Create inclusive clinical environments that are affirming to queer patients, staff, and students.

Online Course: Teaching LGBTQ+ Health

Teaching LGBTQ+ Health is a new, online, faculty development course designed to bridge the gap between the expectation of faculty teaching competency and a lack of previous training. The intended audience includes educators across the health professions, though the content is also made freely available to all providers, students, patients, and other interested individuals.

This course serves as an introductory primer that assumes no prior knowledge of LGBTQ+ health issues. The course includes both LGBTQ+ health content and recommendations for teaching this material to trainees in any discipline or clinical department. Educators may freely download portions of the course for use in their daily clinical teaching or their school’s curriculum.

This online course is divided into modules that review topics such as LGBTQ+ Vocabulary, Social and Behavioral Determinants of Queer Health, Disease Prevention, and Teaching Strategies, among others. A comprehensive glossary of key terms and 3 interactive, clinical case examples are provided to reinforce key concepts. The entire course is evidence-based and extensive references to medical literature are provided. 

If you learn something new by from our course, we respectfully ask that you share the course within your clinical department and with a few colleagues outside your institution.

By |2021-03-19T10:57:09-07:00Mar 23, 2021|CME, Public Health|

Introducing CME for ALiEM via FOAMbase

foambase-aliem-logo-sml cmeEver wish you could get Continuing Medical Education (CME) credit for the Free Open Access Meducation (FOAM) you already consume? We are excited to announce that 10 ALiEM articles are now available for AMA PRA Category 1 CME. This is a pilot program in collaboration with FOAMbase and EB Medicine. There is great content on trauma, geriatrics, pediatrics, critical care, and more. We think CME for FOAM is going to be a great way to increase sustainability for FOAM authors while keeping FOAM 100% free and open access.



By |2017-03-05T14:13:02-08:00Oct 15, 2016|CME, Medical Education, Social Media & Tech|

PEM Pearls: Perfecting your pediatric lumbar puncture using ultrasound

lp_collect-croppedA lumbar  puncture (LP) is a common procedure that every emergency physician must master. Pediatric LPs can be challenging for even the most experienced clinician due to small anatomy, difficulty with patient cooperation, and lack of frequency performed. A successful procedure is defined by obtaining cerebrospinal fluid and/or performing a non-traumatic lumbar puncture. There are multiple variables that lead to a successful pediatric lumbar puncture including provider experience, use of anesthesia, and patient positioning. Success rates for pediatric lumbar punctures are variable, with a large range from 34%-75%.1


By |2017-10-26T14:33:32-07:00Sep 21, 2016|CME, Pediatrics, PEM Pearls, Ultrasound|

Diagnosing the central slip injury

Extensor Tendon Laceration Finger 6 sm

Figure 1. Laceration overlying proximal interphalangeal (PIP) joint of right second digit. (Photograph by Daniel Ting and Jared Baylis)

A 34-year-old cabinet maker presents to your Emergency Department after accidentally getting his finger caught in a drawer. On examination, he has a superficial, clean laceration over the dorsal surface of the right second digit (Figure 1).

In a previous post, we discussed the approach to identifying, treating, and managing extensor tendon injuries of the hand. In it, we advocate for a high index of suspicion for extensor tendon injuries whenever a patient suffers a laceration to the dorsal aspect of the hand. However, lacerations over the PIP joint deserve special mention. In this article, we focus on the diagnosis of a specific type of extensor tendon laceration: the central slip injury.


By |2017-03-11T00:19:16-08:00Jul 25, 2016|CME, Expert Peer Reviewed (Clinical), Orthopedic|

Extensor tendon injuries of the hand: Emergency Department management

hand laceration -225x300You are working in the treatment area with a medical student and she is ready to review a “straightforward” case with you. She presents a young, healthy 27-year-old man with a laceration over the dorsal surface of the left hand after a kitchen mishap. It appears clean, and she doesn’t suspect a foreign body. The neurovascular status seems okay with the intact ability to extend the fingers. Her plan is to repair the wound and send the patient for follow up in 7 to 10 days with his family physician for suture removal. The wound appears superficial, but you are an astute clinician and wonder if the skin laceration might not be the only injury. Is there an associated extensor tendon injury?


Extensor tendon injuries of the fingers, hand, and wrist are frequently seen in the emergency department. One recent study found 33.2 tendon injuries to the hand/wrist per 100,000 person-years.1 These injuries occur more often in males than females and have their highest incidence between 20 and 29 years of age.1,2


Extensor tendons are superficial and as such are easy to injure. Over the dorsum of the hand, the extensor tendons form a network of fibers connected by the juncturae tendinum [Figure 2]. These can mask an extensor tendon injury because an uninjured adjacent tendon may compensate for extensor movement.


Figure 2: Extensor tendons of the hand with juncturae tendinum as illustrated by black marker. (Photo by Daniel Ting and Jared Baylis)


Which structures are injured depends on the zone of injury. Injuries can occur to the common extensor tendon, the lateral bands, the central slip, and/or the terminal extensor tendon. The zones of injury are broken down anatomically into zones I through VIII, allowing a universal language for the description of hand/wrist injuries [Figure 3].

Verdan's zones of the Hand, used as a common language for description and management of extensor tendon injuries to the hand. Image created by Brian Lin, MD

Figure 3. Verdan’s zones of the Hand, used as a common language for description and management of extensor tendon injuries to the hand. Image created by Brian Lin, MD

There are specific anatomical considerations for extensor tendons overlying the fingers, especially over the proximal interphalangeal joint, where the central slip may be injured. Injuries of the central slip will be covered in our next post.

Physical exam

Test each extensor joint through active range of motion against resistance. If there is any uncertainty, compare it to the other hand.  The key to diagnosing an extensor tendon injury is to maintain a high index of suspicion. Do not forget to test the distal joint to identify a subtle mallet finger injury.

1. Exam: Proper exposure

In the case of open extensor tendon injuries, achieve proper exposure to assess the tendon. This requires good lighting, analgesia, positioning, and hemostasis. Adequate analgesia can be achieved using a nerve block with lidocaine or bupivicaine.3 Next, depending on the location of the injury, use a Penrose drain or a sphygmomanometer to achieve a bloodless field [Figures 4-5].


Figure 4: The Penrose drain method to obtain digit hemostasis. A) After anesthesia is infiltrated, start by wrapping the Penrose drain from a distal to proximal direction. B) Continue wrapping until the end of the digit reached. C) Begin unwrapping the drain from distal to proximal. D) Clamp the drain to hold the Penrose in place. (Photos by Daniel Ting and Jared Baylis)



Figure 5: The sphygmomanometer method to achieve hemostasis for wounds proximal to the finger. Apply cast padding (stockinette) to the forearm, inflate a blood pressure (BP) cuff to 260 mmHg, and then clamp the cuff tubes with Kelly clamps. This is usually well tolerated by the patient for up to 15-20 minutes [6]. (Photo by Daniel Ting and Jared Baylis)

Once hemostasis is achieved, the joint underlying the injured area should be visualized through its full range of motion to identify any partial tendon injuries.


The above video from LacerationRepair.com summarizes the key points of the exam (additional pearls/pitfalls regarding the exam from the site).

One key pitfall is not having enough exposure since the actual laceration can be very small or proximal/distal to the skin laceration, such as when injury occurs while the hand is in a fist. Lacerations can be extended to properly visualize the injury [Figure 6].

Finger Diagrams_2-s

Figure 6: Wounds may be extended by making small incisions (approximately 1 cm) at a 90 degree angle to the ends of the laceration, with subsequent unfolding of the skin. Often only a proximal extension of the wound is needed as it is the proximal end that is harder to find. Once unfolded, the skin is held in place using a suture or skin hooks. (Illustration by David Ting)

A video demonstrating wound extension technique can be seen below from LacerationRepair.com, along with a description of additional tests used in the diagnosis of extensor tendon injury in specific hand zones from the site.


Extensor tendon injuries fall into 2 general categories: open versus closed. Both rely on a high index of suspicion and careful physical examination. Closed injuries only require splinting in a volar extension splint [Figure 7] with a hand surgery follow-up within 1 week.2


Figure 7: Volar extension splint, supporting the arm and hand in neutral position. (Photo by Daniel Ting and Jared Baylis)


Some open injuries can be repaired in the ED, and some will need delayed repair by a hand surgeon. Ultimately, all these injuries (repaired or not) need hand surgeon follow up in one week.


Figure 8: Suggested management algorithm for extensor tendon injuries of the hand. (Graphic by Daniel Ting)

Which injuries can be repaired in the ED?

  • Zone I: Mallet finger, treated with continuous extension splinting of the DIP joint and referral to a hand surgeon for follow-up.4
  • Zone II-IV: May repair in the ED 2,3
  • Zone V: Suspect a human bite from a clenched fist hitting a person’s teeth (“fight bite”).5 Refer for delayed repair by a hand surgeon unless the injury was caused by a sharp, clean object.6
  • Zone VI: May repair in the ED, often easy technically because the juncturae minimize tendon retraction.2
  • Zone VII and VIII: The extensor retinaculum is in this area. Excessive trauma increases risk of adhesion formation.2 Refer to a hand surgeon for repair.

Contraindications to ED repair

  • “No-go” hand zones (VII, VIII)
  • Thumb involvement
  • Open fracture
  • Neurovascular compromise
  • Gross contamination
  • Immunocompromised patients or those who are considered elite athletes 4

Complete versus partial tendon disruption

Complete tendon lacerations need to be repaired. Partial tendon lacerations are more controversial; however, it is generally recommended to repair (either in the ED or OR) if the laceration involves >50% of the tendon diameter. Lacerations involving <50% usually need 6 weeks of splinting in extension with hand surgeon and hand therapist follow-up.

Choice of suture

The best choice is a braided non-absorbable suture, such as Ethibond.2 Prolene can be used but is considered suboptimal because it stretches over time. Nylon sutures are sharp and can tear through the tendon.

For size, our local plastic surgeon group recommends the largest suture that the tendon can tolerate to maximize retention strength. 3-0 is a common size choice for extensor tendon repair of the hand where the tendons are thicker and can accommodate core sutures.7 For extensor tendon repair in the fingers, a 4-0 is often selected,2,7 although a 3-0 or even a 2-0 could be used if the tendon is large enough.

A tapered needle is preferred as it is less traumatic when compared to a cutting needle.2

Suture strategy

There are many techniques of suture repair and you will find differing recommendations depending on your source. The figure-of-8 is an acceptable technical choice3 because:

  1. It is familiar to emergency physicians.
  2. The number of suture strands across the repair site correlates with tensile strength.8

Be gentle when manipulating the tendon to minimize additional trauma. Use only single toothed forceps on the exposed cut end of the tendon with as little force as possible.

In certain situations, a more advanced practitioner might also consider use of a grasping suture technique, demonstrated in the following video (more information on their indications).



Even when extensor tendon injuries are repaired in the ED, hand surgeon follow-up in 7 days is required for reassessment, skin suture removal, and referral to hand physiotherapy for strengthening and range of motion. There is a dearth of evidence for prophylactic antibiotics, but they are often prescribed.2,4 If you are unable to adequately assess a suspected extensor tendon injury, close the skin, place the arm in a volar extension splint, and refer to a hand surgeon for follow-up within 7 days.

Case Conclusion

You identify a 50% injury of the extensor tendon in zone VI of the left hand and repair the injury using 3-0 Ethibond. Subsequently, you place the arm in a volar extension splint, and send your patient for follow up with a hand surgeon. His extensor tendon injury recovers beautifully.

Take Home Points for Extensor Tendon Injuries of the Hand

  1. Some extensor tendons of the hands and fingers can be repaired in the ED.
  2. Adequate exposure, a bloodless field, and possible wound extension are needed to properly assess wounds for an extensor tendon injury.
  3. Use 3-0 and 4-0 nonabsorbable braided sutures for extensor tendons of the hand and fingers, respectively.
  4. Use a figure-of-8 technique for suturing extensor tendon lacerations in the ED.
  5. Apply a volar extension splint and refer for hand surgeon follow-up within 7 days, regardless of ED repair.
de J, Nguyen J, Sonnema A, Nguyen E, Amadio P, Moran S. The incidence of acute traumatic tendon injuries in the hand and wrist: a 10-year population-based study. Clin Orthop Surg. 2014;6(2):196-202. [PubMed]
Bowen W, Slaven E. Evidence-Based Management Of Acute Hand Injuries In The Emergency Department. Emerg Med Pract. 2014;16(12):1-24. [PubMed]
Calabro J, Hoidal C, Susini L. Extensor tendon repair in the emergency department. J Emerg Med. 1986;4(3):217-225. [PubMed]
Katzman B, Klein D, Mesa J, Geller J, Caligiuri D. Immobilization of the mallet finger. Effects on the extensor tendon. J Hand Surg Br. 1999;24(1):80-84. [PubMed]
Amirtharajah M, Lattanza L. Open extensor tendon injuries. J Hand Surg Am. 2015;40(2):391-7; quiz 398. [PubMed]
Marx J, Walls R, Hockberger R. Rosen’s Emergency Medicine – Concepts and Clinical Practice. Elsevier Health Sciences; 2013.
Dy C, Rosenblatt L, Lee S. Current methods and biomechanics of extensor tendon repairs. Hand Clin. 2013;29(2):261-268. [PubMed]
Lim B, Ooi L, Chou S, Goh K. Biomechanical properties of extensor tendon repair using the six-strand single-loop suture technique: a comparative analysis with three other techniques in cadaveric models. J Mech Med Biol. 2011;11(4):845-855.
By |2022-04-22T09:34:58-07:00Jul 18, 2016|CME, Expert Peer Reviewed (Clinical), Orthopedic|

5 Tips for Managing Pain in Older Adults

painPain is the most common reason people seek care in Emergency Departments. In addition to diagnosing the cause of the pain, a major goal of emergency physicians (EPs) is to relieve pain. However, medications that treat pain can have their own set of problems and side effects. The risks of treatment are particularly pronounced in older adults, who are often more sensitive to the sedating effects of medications, and are more prone to side effects such as renal failure. EPs frequently have to find the balance between controlling pain and preventing side effects. Untreated pain has large personal, emotional, and financial costs, and more effective, multi-modal pain management can help reduce the burden that acute and chronic pain place on patients.1 There is evidence that older adults are less likely to receive pain medication in the ED.2,3 The first step to improving, is being aware of the potential tendency to under-treat pain in older adults. Here are 5 tips to help you effectively manage pain in older adults on your next shift.


By |2016-12-16T15:29:06-08:00May 25, 2016|CME, Geriatrics, Tox & Medications|

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?


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).


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

AgentDoseAdverse eventsEvidence supporting efficacyNotes
Acetaminophen (APAP)14,151 gm IVWell toleratedIn one trial, IV APAP did no better than placebo. In another, IV APAP was comparable to an IV NSAID.
Dihydroergotamine160.5 mg -1 mg IV infusionNausea 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.
Ketamine170.08 mg/kg SCFatigue, deliriumIn one low quality cross-over RCT, ketamine outperformed placebo.
Magnesium18–211-2 gm IVFlushingIn RCTs of varying quality, IV mg did not consistently outperform placeboEfficacy data is most compelling for migraine with aura.
Octreotide220.1 mg SCDiarrhea, injection site reactionsIn a high quality RCT, octreotide did not outperform placebo
Propofol23,2410 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 mgSedation, hypoxiaIn 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 acid28,291000 mg IVWell toleratedIn 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.


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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]
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By |2019-04-28T21:14:07-07:00May 18, 2016|CME, Neurology, Tox & Medications|
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