When Should You Go to the ER with a Migraine?

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You’ve been suffering through a migraine that just won’t stop. Or you start experiencing some scary symptoms, like numbness, tingling, visual aura or passing out. Or you get a shockingly sharp and sudden pain unlike any migraine before. These are among the reasons migraine sufferers go to the ER (Emergency Room in the US) or A&E (Accident & Emergency in the UK), often despite bad experiences in the past.

For many, the going to the ER with a migraine is a last resort.

As one patient, Cheryl Stoutenberg Robinson, shared on our Facebook page: “The last time I went, I thought I was having a stroke. I waited for hours. They put me in a dark room, and when the doc finally saw me… I knew it was a hemiplegic migraine and the doc gave me an aspirin and wanted to give me IV fluids, but since I had been there for sooooo long, I just wanted to go home to my own bed with the knowledge that I wasn’t having a stroke. Our ER does not give narcotics or use triptans. The only thing they will do is give you chlorpromazine by IV and make you stay for hours.”

To understand what really happens in the ER, check out Part 1 in our 3 part series on Migraine Emergencies here. It may be an absolutely necessary evil for you.

When You Should Go to the ER with a Migraine

According to the Agency for Healthcare Research and Quality, it’s essential to rule out stroke or another life-threatening cause of intense headaches — which ER doctors are equipped to do better than anyone else, even your own physician. The symptoms can mimic a migraine, and even for frequent sufferers, it can be difficult to tell the difference. You should go to the hospital right away if:

You have an extremely severe headache (it could be a migraine, or it could be something more serious)
You have speech, vision, movement, or balance problems that are new or different from symptoms you have had before with your migraines
You have a stiff neck or fever with your headache
The headache starts suddenly, like a “thunderclap,” especially if you are over age 50
Acute Treatment Protocol for Emergency Rooms

Yet by reading our readers’ personal stories, it’s clear that all ERs are not created equal, and don’t even follow the same migraine treatment protocol. A 2012 report by two leading neurologists, Dr. Amy Gelfand an Dr. Peter Goadsby, gives hospital physicians a protocol and recommended medications for the best-in-class treatment of migraine in the ER. They recommend:

Diagnosis: Reassurance, assuming one is confident of the diagnosis, that this is migraine and can be controlled;
Hydration: ensure adequate hydration;
Control: first control headache; and then control associated features, particularly nausea, while also considering photophobia and phonophobia through treatment in an appropriate environment. (Read: dark, quiet space).
If you’re wondering what in the world you’re being given to control your migraine in the ER, you may want to print out this list of Drugs Used in Emergency Room Management of Migraine. It does not include all the options for nausea (like Phenergan). And these are not universally used; just recommended by migraine doctors.

5 Alternatives to Using the ER for Migraine Care

Given all the unpleasant and dramatic stories about ER treatment, you may be wondering: what’s the alternative? If it’s a scary migraine with new complications, the ER is your safest bet. If it’s an intractable migraine that won’t respond to treatment at home, you have a few options.

1 – Change Your Approach: There are literally dozens of migraine treatments in our website here, from prescription to over-the-counter to home remedies that have good evidence behind them, and work for many. Ask for help to comb through them, and see if there’s one you can try instead of your usual treatment that’s failing. You may need to request a prescription or make a trip to the store, but it’s better than 5-6 hours in the ER.

2 – Talk to a Doctor Online: Using a telemedicine platform like HealthTap from anywhere in the world, you can reach one of thousands of qualified US doctors via an app on your smart phone 24/7 for far less money than a traditional co-pay. They can call in prescriptions too. Rates vary, but can run $20-44 per consult.

3 – Ice Up and Wait: Hydrate heavily, administer ice frequently with a better ice pack (see our picks here), and try to sleep (using Benadryl, magnesium or melatonin if necessary) until your doctor’s office opens up. Says Larisa Gokool: “If the choice is between having a three-day plus migraine where nothing is helping and I’m crying because I’ve been in pain for so long in my quiet house (with tinted windows covered with black out curtains) with my quiet dog and quiet husband who take care of me or a brightly lit, bright white-walled, smelly, loud expensive hospital ER, I’ll wait it out under my blankets where I can at least control my surroundings.”

4 – Go to Urgent Care: They’re close by, service oriented, and you won’t be understandably waiting behind a broken leg. It’s typically much less expensive too. Many are pleased with the care they get there: “I’ll go to Urgent Care (which is like a doctor’s office that you don’t have to make an appointment for, basically) but not the ER” says Anna Kane. “I’ll only go to Urgent Care when I’m starting to lose vision and get that “flutter” over one eye, though. A shot of Imitrex, a shot of Zofran, and they will even dim the lights and let me lay back for a bit while it kicks in if they’re not super busy. One time, one of the women at the desk even came in to the waiting room to turn off the TV while I was waiting. They are really good when it comes to migraines.”

5 – Request Home Rescue Medications from Your Doctor: While this isn’t available 24/7, you can ask your MD to show you how to administer some of the same meds they’d give you at the hospital. “I found that all they do is give you a shot of toradol or some other narcotic, nauseous medicine, and benadryl they say that it makes you sleep” said Skipper Davis. “So my doctor set me up with the shots that I do at home and the pills for nausea but I don’t take the benadryl. The nausea pill usually puts me down.” That might be the injectable forms of Toradol or DHE-45 and Phenergan, available by prescription. For sufferers like Teresa Powell, this has been a life-changing option to deal with intractable cluster migraines.

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