醫學筆記匯整 ED Notes

http://painandpsa.org/headache/

 Migraine 

Dopamine Antagonists 

PO anti-dopaminergics have emerged as first-line therapy for migraine.
- Prochlorperazine 10 mg (Novamin)
- Chlorpromazine 25 mg (Wintermin)
- Metoclopramide 10mg (Primperan)
- Haloperidol 5 mg
- Droperidol 2.5mg

droperidol 2.5 mg IV is probably the most efficacious,
followed by prochlorperazine 10mg IV. 

- 注意 EPS 副作用 : 尤其是 akathisia (restlessness)
   The incidence of akathisia can be minimized by
   administering these medications as a 15 minute infusion.
   Prochlorperazine should be administered with diphenhydramine 25mg IV
   to prevent development of akathisia. 

NSAIDs

- Ketorolac, dosed at 15 mg IV or 30 mg IM,
   has a modest evidence base supporting use.
- Demonstrating the efficacy of an oral NSAID,
  such as ibuprofen or naproxen

Triptans 

- The only available parenteral version is sumatriptan
- serotonin agonists : relieve headache through cerebral vasoconstriction
- triptans : used cautiously in patients with cardiovascular risk factors
- Oral triptans :
  Sumatriptan 100 mg PO, eletriptan 40 mg PO, and almotriptan 6.25 mg PO
  are reasonable treatments for patients who prefer oral treatment.
  These latter medications can be combined with oral NSAIDs (naproxen 500 mg PO)

Corticosteroids
- Corticosteroids decrease the occurrence of moderate or severe headache
  post ED-discharge with a number needed to treat of 9
  and should be offered to all patients who have no contraindications.

- Corticosteroids do not result in rapid improvement, 
  but it is likely that their effects will occur within a six-hour window.

- Dexamethasone 10 mg as a one time IV, IM, or PO dose is reasonable

- Alternatively, patients may be discharged on a
  short course of oral prednisone (eg, 40-60 mg daily for three days).

Opioids, Barbiturates, Magnesium, DHE 省略 

= 當然前提是完全排除了其他原因, 很確定是 Migraine = 

Novamin+Vena is effective for treating migrainous headache.
- A Comparison of Headache Treatment in the Emergency Department :
  Prochlorperazine Versus Ketamine.

 Cluster Headache 

- Feel restless and prefer to move rather than lie in a dark room
- Peaks in intensity quickly and does not last longer than 3 hours

- should be treated with high flow oxygen
  12 L/ minute through a non-rebreather mask (要戴到 NRM ...)

- Subcutaneous sumatriptan, dosed at 6 mg
- Anti-dopaminergics are thought to be useful for acute cluster too,
  though evidence is of lower quality

- Next headache in the cluster cycle is very likely to occur within 24 hours
- Corticosteroids are thought to mitigate the frequency
  and severity of subsequent headaches.
  It is reasonable to provide these patients with a 10 day corticosteroid taper. 

 Medication overuse headache + Chronic headache 

- A downstream complication of the primary headache disorders
- is characterized by an upward spiral in headache frequency
  associated with an increased use of analgesic or headache specific medication

- Chronic migraine should be treated with preventive medication,
  the goal of which is a modest decrease in the frequency and severity of acute attacks.
  Anti-hypertensive medications including beta-blockers, and CCB can achieve this goal,
  as can antiepileptic medications including topiramate and valproic acid,
  and the TCA.

- Chronic migraine : 
  The combination of NSAID with an oral triptan or with oral metoclopramide
  is a reasonable starting point on effective acute medication.

- For patients with medication overuse headache : slow taper,  is required  

Summary : 

- Acute primary headache may present to the ED
  with a variety of different acute manifestations

- After excluding secondary headache,
  goal should be on rapid and effective relief of pain

- Disease specific treatments such as anti-dopaminergics and triptans
   results in better short and long-term outcomes than non-specific analgesics

- Opioids should not be used for management of primary headache disorders
  unless several other treatments have failed

- Recurrent primary headache after ED discharge is common.