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Effective Alternatives to Narcotics for Severe Headache

Effective Alternatives to Narcotics for Severe Headache

Many patients who present to the emergency department (ED) with severe headache request a narcotic to relieve the pain. Past histories are sometimes difficult to document, especially on weekends or if the patient is "visiting from outof- town." If the patient claims that the current headache is similar to past headaches and is not of new onset or of a different intensity, duration, or nature, what effective alternatives to narcotics and antiemetics can be given? -- James E. Hill, PA-C, MEd
  &nbspCharlotte, NC
Most patients who come to the ED with a severe headache have migraine. Several alternative therapies can be used instead of narcotics to treat acute headache:

  • Intravenous dihydroergotamine is often very effective, even if used well into an attack; however, it is contraindicated in patients with hypertension or coronary artery disease. It is best given after an antinausea drug, such as metoclopramide, is administered.
  • Intravenous sodium valproate is also very effective at terminating a migraine attack.
  • Intravenous prochlorperazine may be effective; in any event it usually causes sedation and sleep, which are helpful in breaking an attack.
  • Intravenous magnesium is occasionally useful.
  • Intravenous or intramuscular ketorolac tromethamine is often very effective for relieving migraine or even a severe tension-type headache.
  • Corticosteroids, such as intravenous methylprednisolone or intravenous dexamethasone (or the depot form of these drugs, given intramuscularly), can be very helpful when used in addition to a primary medication.
  • Solid evidence shows that narcotics usually provide only transient relief from pain. Most patients who find narcotics helpful probably benefit from the sleep they induce.

-- Robert S. Kunkel, MD
  &nbspHeadache Center
  &nbspThe Cleveland Clinic Foundation
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