sean kelcey ccpa em pa selkirk regional health center ... · em pa selkirk regional health center...
TRANSCRIPT
Sean Kelcey CCPA EM PA Selkirk Regional Health Center
Selkirk, MB CAPA 2017
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
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
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
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?
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
“I had a bad reaction to something they gave me last time”
LOOKS UNWELL; eyes covered, wants lights out
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
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
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)
D. during headache, at least one of the following is present:
- nausea and / or vomiting
- photophobia and phonophobia
E. not attributed to another disorder
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
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
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
Migraine lasting > 72 hours, despite or without treatment
SINISTER MIMICS
SAH
MENINGITIS/ENCEPHALITIS
STROKE/TIA
GCA
NON SINISTER MIMICS CLUSTER HEADACHES
SINUSITIS
TENSION HEADACHE
DRUG OVERUSE HEADACHE
OCCIPITAL NEURALGIA
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
CONJUCTIVAL INJECTION/TEARING/FACIAL SWELLING TO IPSILATERAL SIDE
MALE>FEMALE ~4:1 (women do get them though – don’t ignore)
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
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
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
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
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
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
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
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…
IF YOU EVEN REMOTELY SUSPECT IT,
CT THE HEAD!!!!!!!!!
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
IF YOU’RE CONCERNED, ORDER LABS, CT/LP AND TREAT EMPIRICALY FOR WHAT YOU’RE SUSPECTING
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
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
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
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
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
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
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
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
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
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
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
ONCE H/A IS SETTLING, DO A CLOSER EXAM, ESPECIALLY THE FUNDI
ALWAYS HAVE A BACK UP PLAN IN PLACE WITH SECONDARY/TERTIARY MEDS
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
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
MRS A
DX=?
STATUS MIGRAINOSUS
TMT:
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
MISS B
DX?:
TENSION TYPE HEADACHE
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
MISS C
DX?:
OCCIPITAL NEURALGIA
TMT:
Initially received Cocktail #1, 2/10 change on pain scale…observably improved with occipital nerve block with steroid. Discharged ~ 2hours post initial assessment.
QUESTIONS?
QUERIES?
RUDE COMMENTS?
https://headachesociety.ca/guidelines/
https://americanheadachesociety.org