Effective Alternatives to Narcotics for Severe Headache

Many patients who present to the emergency department(ED) with severe headache request a narcotic to relieve thepain. 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 issimilar to past headaches and is not of new onset or of a differentintensity, duration, or nature, what effective alternativesto narcotics and antiemetics can be given?-- James E. Hill, PA-C, MEd
  &nbspCharlotte, NCMost patients who come to the ED with asevere headache have migraine. Severalalternative therapies can be used insteadof narcotics to treat acute headache:

• Intravenous dihydroergotamine isoften very effective, even if used well into an attack; however,it is contraindicated in patients with hypertension orcoronary artery disease. It is best given after an antinauseadrug, such as metoclopramide, is administered.
• Intravenous sodium valproate is also very effective atterminating a migraine attack.
• Intravenous prochlorperazine may be effective; in anyevent it usually causes sedation and sleep, which are helpfulin breaking an attack.
• Intravenous magnesium is occasionally useful.
• Intravenous or intramuscular ketorolac tromethamine isoften very effective for relieving migraine or even a severetension-type headache.
• Corticosteroids, such as intravenous methylprednisoloneor intravenous dexamethasone (or the depot form ofthese drugs, given intramuscularly), can be very helpfulwhen used in addition to a primary medication.

Solid evidence shows that narcotics usually provideonly transient relief from pain. Most patients who find narcoticshelpful probably benefit from the sleep they induce.

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