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
Charlotte, 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(Drug information on 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(Drug information on metoclopramide), is administered.
- Intravenous sodium valproate is also very effective at terminating a migraine attack.
- Intravenous prochlorperazine(Drug information on 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(Drug information on ketorolac) tromethamine is often very effective for relieving migraine or even a severe tension-type headache.
- Corticosteroids, such as intravenous methylprednisolone(Drug information on methylprednisolone) or intravenous dexamethasone(Drug information on 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
The Cleveland Clinic Foundation