Many patients who present to the emergency department
(ED) with severe headache request a narcotic to relieve the
pain. 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 is
similar to past headaches and is not of new onset or of a different
intensity, duration, or nature, what effective alternatives
to narcotics and antiemetics can be given?
-- James E. Hill, PA-C, MEd
Most patients who come to the ED with a
severe headache have migraine. Several
alternative therapies can be used instead
of narcotics to treat acute headache:
- Intravenous dihydroergotamine is
often very effective, even if used well into an attack; however,
it is contraindicated in patients with hypertension or
coronary artery disease. It is best given after an antinausea
drug, such as metoclopramide, is administered.
- Intravenous sodium valproate is also very effective at
terminating a migraine attack.
- Intravenous prochlorperazine may be effective; in any
event it usually causes sedation and sleep, which are helpful
in breaking an attack.
- Intravenous magnesium is occasionally useful.
- Intravenous or intramuscular ketorolac tromethamine is
often very effective for relieving migraine or even a severe
- Corticosteroids, such as intravenous methylprednisolone
or intravenous dexamethasone (or the depot form of
these drugs, given intramuscularly), can be very helpful
when used in addition to a primary medication.
Solid evidence shows that narcotics usually provide
only transient relief from pain. Most patients who find narcotics
helpful probably benefit from the sleep they induce.
-- Robert S. Kunkel, MD
The Cleveland Clinic Foundation