Sean Kelcey CCPA EM PA Selkirk Regional Health Center Selkirk, MB CAPA 2017

Transcription

1 Sean Kelcey CCPA EM PA Selkirk Regional Health Center Selkirk, MB CAPA 2017

2 I HAVE NO FINANCIAL DISCLOSURES TO MENTION AND DO NOT REPRESENT ANY DRUG DEALERS, LEGAL OR OTHERWISE ANY MENTION OF BRAND NAME AGENTS IS PURELY BY ACCIDENT OR BECAUSE THEY RE EASIER TO SAY GENERIC NAMES WILL ONLY BE SHOWN HERE IN TEXT FORM

3 CASE INTRODUCTIONS MIGRAINE TYPES TYPICALLY SEEN NON-SINISTER HEADACHES THAT MIMIC MIGRAINE SINISTER HEADACHES THAT MIMIC MIGRAINE PHARMACOLOGIC AGENTS USED IN TREATMENT OF ACUTE MIGRAINE CANADIAN AND US HEADACHE SOCIETY GUIDELINES SEAN S MIGRAINE APPROACH AND COCKTAILS CASE RESOLUTIONS

4 MIGRAINE AFFECTS ~ 4 MILLION PEOPLE IN CANADA ~25% OF CANADIAN WOMEN AND ~7-10% OF CANDIAN MEN ARE THOUGHT TO BE AFFECTED A TOP 20 REASON FOR MEDICAL DISABILITY WORLDWIDE LOTS OF THEORIES NOT MANY ANSWERS, YET

5 EVER NOTICE HOW EVERY H/A IN THE ER IS A MIGRAINE? AND EVER NOTICE HOW MANY OF THESE HEADACHES CAUSE US MIGRAINES IN THE ER? EVER NOTICE MONDAYS SUCK?

6 35 YO F, H/A X 5/7 KNOWN MIGRAINEUR, Dx By FMD, 6/12 post-partum, otherwise healthy; H/A s started during pregnancy (+) Phono/photosensitivity, N/V; pain hemispheric to (L), pounding; visual disturbance prior - dancing lights Onset was insidious; usual abortive therapy not effective Denies N/T or focal loss of function, Fever/chills/ns/neck stiffness or sick contacts/bad habits/known triggers

7 I had a bad reaction to something they gave me last time LOOKS UNWELL; eyes covered, wants lights out

8 42 YO F, 2/52 Hx HA I have a migraine No formal Dx Migraine; generally healthy Pain is unilateral but changes side, squeezing /c scalp burning; some relief with NSAID s (+) phonosensitivity and some nausea; ^ personal stressors Denies fever/chills/ns/urti symptoms/vomiting/focal neuro symptoms/bad habits/aura Looks tired in a well lit room

9 26 YO F, H/A x 1/7 No known migraine Hx, healthy Pain is (L) scalp/eye with pain increasing /c turning head I get a shock when I do that ; insidious onset; little change with NSAID s (+) photo/phonosensitive, mild nausea; moves keeping head still Denies Fever/chills/ns/vomiting/focal neuro symptoms/aura Looks in pain in a well lit room, squinting but cooperative

10 A. At least 5 attacks fulfilling criteria B-D B. Headache attacks lasting 4-72 hours (untreated or unsuccessfully treated) C. Headache has at least two of the following characteristics: - unilateral location - pulsating quality - moderate or severe pain intensity - aggravation by or causing avoidance of routine physical activity (e.g., walking or climbing stairs)

11 D. during headache, at least one of the following is present: - nausea and / or vomiting - photophobia and phonophobia E. not attributed to another disorder

12 A. At least 2 attacks fulfilling criteria B-D B. Aura consisting of at least one of the following, but no motor weakness: 1. fully reversible visual symptoms including positive features (e.g., flickering lights, spots or lines) and/or negative features (i.e., loss of vision) 2. fully reversible sensory symptoms including positive features (i.e., pins and needles) and/or negative features (i.e., numbness) 3. fully reversible dysphasic speech disturbance

13 C. At least two of the following: 1. homonymous visual symptoms and/or unilateral sensory symptoms 2. at least one aura symptom develops gradually over 5 minutes and/or different aura symptoms occur in succession over 5 minutes 3. each symptom lasts 5 and 60 minutes

14 D. Headache fulfilling criteria B-D for Migraine without aura begins during the aura or follows aura within 60 minutes E. not attributed to another disorder

15 Migraine lasting > 72 hours, despite or without treatment

16 NON SINISTER MIMICS CLUSTER HEADACHES SINUSITIS TENSION HEADACHE DRUG OVERUSE HEADACHE OCCIPITAL NEURALGIA SINISTER MIMICS SAH MENINGITIS/ENCEPHALITIS STROKE/TIA GCA

17 WHILE NOT TRUE MIGRAINE, ARE DEBILITATITING AND DO PRESENT TO ER AND SOMETIMES RESPOND TO TYPICAL MIGRAINE MEDS CRITERIA FOR CLUSTER H/A: FREQUENT (up to 8/day) BRIEF (<3hours) RECURRENT (Days/weeks at a time, then stop) UNILATERAL

18 CONJUCTIVAL INJECTION/TEARING/FACIAL SWELLING TO IPSILATERAL SIDE MALE>FEMALE ~4:1 (women do get them though don t ignore)

19 HEADACHE CAN BE UNILATERAL OVER AFFECTED SINUS OR BILATERAL OVER AFFECTED SINUSES CAN BE AT THE VERTEX (sphenoidal sinuses) ASSOCIATED WITH PHOTOPHOBIA, SOMETIMES FEVER, USUALLY URTI/ALLERGIC RHINITIS SYMPTOMS SINUSES USUALLY TENDER; IF MAXILLARY, OFTEN ASSOCIATED WITH DENTAL PAIN

20 USUALLY DON T MEET CRITERIA FOR MIGRAINE TYPICALLY ARE: BILATERAL, SQUEEZING, WITH MILD TO MODERATE INTENSITY NON-PULSATING NOT WORSENED BY ACTIVITY USUALLY NON-NAUSEATING

21 Often seen in migraine patients, undiagnosed migraine patients or patients with tension H/A s that are using primary meds at least 15 days a month Some chronic migraineurs are on the wrong abortive meds and haven t discussed changing with their PCP Some patients have an underlying dyscopia chronic pain, depression, PD, etc

22 Common offenders are triptans, NSAID s, ASA/APAP preps, especially those with caffeine, and opiods. These people need a withdrawal strategy, with a frank discussion regarding expectations of pain management They also need to try a new abortive med new triptan, DHE or alternative with an adjunct until the H/A s lessen in frequency, as well as exercise, stress management and management of underlying D/O

23 A TYPE OF HEADACHE THAT CAN OFTEN BE SEEN WITH MIGRAINE OR AS STAND ALONE POOR UNDERSTANDING OF MECHANISM OFTEN ASSOCIATED WITH TENSION/SPASM OF TRAPS/PARACERVICAL MUSCLES PAIN CAN BE UNILATERAL OR BILATERAL, BURNING/STABBING IN QUALITY, INCREASING WITH MOVEMENT, OFTEN AN ELECTRIC SHOCK SENSATION

24 TENDERNESS ALONG GREATER/LESSER OCCIPITAL NERVE DISTRIBUTION SOME PEOPLE EXHIBIT PHOTOSENSITIVITY AND NAUSEA CAN BE TREATED WITH CONSERVATIVE MEASURES, PHYSIO +/- A NERVE BLOCK /C OR /S STEROIDS

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26 ONE OF THOSE CAN T MISS H/A S ACCOUNT FOR LESS THAN 1% OF ER VISITS BUT MISSED ONES ARE A LEADING CAUSE OF ACTIVATION OF MALPRACTICE COVERAGE DON T GET SUCKERED BY A MIGRAINEUR WITH HEADACHE IF IT S A CHANGE IN PATTERN, ESPECIALLY ABRUPT ONSET AND AURA MIMICS IN FORM OF FOCAL NEURO SYMPTOMS

27 HEADACHES THAT ARE ABRUPT, THUNDERCLAP OR ABSOLUTE WORST HEADACHE OF MY LIFE (ESPECIALLY IN A MIGRAINEUR), SUSPECT SAH S&S CAN MIMIC MIGRAINE WITH AURA, ALONG WITH SORE/STIFF NECK, DECREASING LOC, OTHER FOCAL NEURO SYMPTOMS MAY HAVE HX OF TRAUMA, HTN, SMOKING, AVM, OR ON ANTICOAGULANTS

28 IF YOU EVEN REMOTELY SUSPECT IT, CT THE HEAD!!!!!!!!!

29 ANOTHER CAUSE OF ACTIVATION OF MALPRACTICE INSURANCE USUALLY PRESENT WITH PRODROMAL SYMPTOMS FEVER, MYALGIA, ANTECEDENT URTI, POSSIBLE EPIDEMIC EXPOSURE CAN MIMIC MIGRAINE /C OR /S AURA; OFTEN HAVE STIFF NECK ASSOCIATED, BOTH TO ACTIVE/PASSIVE MOVEMENT REMEMBER FORMAL BRUDZYNSKI AND KERNIG SIGNS ARE ONLY (+) 50% ISH

30 IF YOU RE CONCERNED, ORDER LABS, CT/LP AND TREAT EMPIRICALY FOR WHAT YOU RE SUSPECTING

31 ODDLY ENOUGH, CAN MIMIC MIGRAINE WITH AURA AND VICE VERSA KEY IS AURA ON/OFF TIMINGS IF PATIENT PRESENTS LIKE MIGRAINE WITH AURA, BUT HAS NO PREVIOUS HX, ASSUME STROKE UNTIL PROVEN OTHEWISE IF MIGRAINEUR PRESENTING WITH ATYPICAL H/A FOR THEMSELVES, ACTIVATE STROKE PROTOCOL

32 IF MISSED, CAN RESULT IN VISION LOSS KEY POINTS USUALLY AN OLDER PERSON (>60 YO) PAIN IS ASSOCIATED WITH JAW CLAUDICATION, USUALLY NO N/V PATIENTS OFTEN HAVE COMORBID PMR PROXIMAL MUSCLE PAIN/WEAKNESS

33 TRIPTANS : SELECTIVE SEROTONIN 5-HT1B/D AGONISTS MOST RECOMMENDATIONS ARE FOR SC SUMITRIPTAN 6MG, RIZATRITPAN 10MG WAFER OR ZOLMATRIPTAN 5MG I/N SPRAY (MORE STUDIES VS SUMITRIPTAN 20MG I/N) UP TO 2 DOSES IN 24HRS FOR MOST OF THESE DRUGS

34 DOPAMINERGICS MOST RECCOMENDED/STUDIED ARE PROCHLORPERAZINE 10-20MG IV OR METOCLOPRAMIDE 10-20MG IV CAN BE USED IN COMBINATION OR AS STAND ALONE METOCLOPRAMIDE HAS ADDED BENEFIT OF ACTING ON 5-HT RECEPTORS

35 ERGOT DERIVATIVES DIHYDROERGOTAMINE (DHE45) CAN BE USED I/N (2MG), SC/IM/IV 1MG POTENT VASOACTIVE AGENT; PREG TEST ALL FEMALE PATIENTS IF CONSIDERING AGENT SHOWN GOOD RESULTS IN LONG TERM RELIEF

36 NSAID S CAN USE PO MEDS IF NOT VOMITING BEST STUDIED ARE NAPROXEN, IBUPROFEN AND ASA; DICLOFENAC SHOWED POOR RESULTS IN STUDIES HOWEVER, IN THE ER, MOST PATIENTS AREN T WILLING TO TRY PO INJECTABLE KETOROLAC IS AVAILABLE IN MOST ER S

37 OXYGEN EFFECTIVE FOR USE IN CLUSTER HEADACHES, HIGH FLOW (12-15LPM) FOR ~15 MINUTES STEROIDS EFFECTIVE FOR PREVENTING RELAPSE OR FOR CONCOMITANT USE WITH OCCIPITAL NERVE BLOCKS; NOT FOR ACUTE H/A

38 LOCAL ANAESTHETICS USUALLY USED FOR OCCIPITAL NERVE BLOCKS COMBO LIDO/BUPIVICAINE +/- STEROID CAN ALSO BE USED IN TRIGGER POINT INJECTIONS FOR PROLONGED TENSION/DRUG OVER USE H/A SMALL STUDIES FOR I/N LIDOCAINE, POOR EVIDENCE

39 CANADIAN AND US GUIDELINES ARE PRETTY SIMILAR BOTH SUGGEST TRIPTANS AS FIRST LINE AGENTS FOR ACUTE ABORTIVE THERAPY IF AVAILABLE AND WITHIN DOSING TIMELINES BOTH ALSO SUGGEST DOPAMINERGIC ANTI-NAUSEANT AGENTS +/- AN NSAID DHE IS ALSO RECOMMENDED AS AN AGENT OF CHOICE

40 ALL UNIVERSALLY RECOMMEND AGAINST OPIOIDS AS FIRST LINE AGENTS STEROIDS ARE RECOMMENDED ONLY TO PREVENT RECURRENCE, NOT AS ACUTE THERAPY SUGGEST H/A DIARY IF NEW PATIENT OR IF TRIGGERS STILL NOT KNOWN, DISCUSS SELF CARE, DRUG OVER USE, ETC WHEN D/C

41 EYEBALL THE PATIENT AND GET A QUICK, TARGETED HX, INCLUDING MEDS USED RAPID NEURO ASSESSMENT INCLUDING TRYING TO GET A LOOK AT THEIR FUNDI AND CHECK THEIR NECK AND LISTEN FOR BRUITS GET IV ACCESS IF NOT ALREADY THERE, GIVE SOME FLUID AND DECIDE ON ABORTIVE THERAPY

42 ONCE H/A IS SETTLING, DO A CLOSER EXAM, ESPECIALLY THE FUNDI ALWAYS HAVE A BACK UP PLAN IN PLACE WITH SECONDARY/TERTIARY MEDS

43 COCKTAIL #1=> 1OOOcc N/S or R/L + ketorolac 15mg/metoclopramide 10mg/diphenhydramine 25mg IV COCKTAIL #2=> see #1, replace metoclopramide with prochlorperazine COCKTAIL #3=> Sumatriptan 6mg sc (if available); may add fluid/ketorolac/antinauseant/diphenhydramine prn

44 COCKTAIL #4=> More fluid, DHE 1mg im/iv, dexamethasone 10mg iv (status migrainosus cocktail or non-responder) Offer occipital nerve block(s) and/or trigger point injections if residual pain in the nerve distribution

45 DX=? STATUS MIGRAINOSUS TMT: MRS A TRIAL OF COCKTAIL #1; PARTIAL RESOLUTION RECEIVED #4 AND WAS PAIN FREE AFTER 4 HOURS AND D/C SAW THEM AGAIN 2/52 LATER, RECEIVED #1 + DEX, OCCIPTAL NERVE BLOCK; WAS GIVE Rx for CCB as a preventative

46 DX?: TENSION TYPE HEADACHE MISS B TMT: Ketorolac IV, trigger point injections/occipital nerve block, stretching exercises, stress management regimen. Returned a few days later requesting another nerve block to opposite side of head was much happier

47 DX?: OCCIPITAL NEURALGIA TMT: MISS C Initially received Cocktail #1, 2/10 change on pain scale observably improved with occipital nerve block with steroid. Discharged ~ 2hours post initial assessment.

48 QUESTIONS? QUERIES? RUDE COMMENTS?

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