Headache protocol

[CBraud]

Does anyone out there currently use a Headache Protocol at their agency? We are considering going to one but mostly what I find are Hypertension Protocols that reference headache in the protocol.

Thank you,
Clint

 

[DesertMedic66]

Is there really a need for a headache protocol?

 

[CBraud]

I'm not sure. I think it would be more for a reference i.e, see Stroke, Hypertension, Pain Management, etc.

 

[GMCmedic]

That seems like a waste of paper.

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[Jim37F]

And what would be in such protocol beyond assess and transport?

 

[VentMonkey]

1. OP, are you really a critical care paramedic?

2. If so, how do you not realize in the face of an otherwise benign complaint of headache there really is not much we can do.

3. Also, what is your reasoning for going to a "headache protocol"? If it is control of blood pressure (i.e., a true hypertensive crisis/ emergency), what is the rationale behind lowering their BP? How will you titrate such BP? Are you arbitrarily going to lower every patients blood pressure who has a headache? Why, or why not?

What if it's, say, a TBI induced hypertensive event- how will this change your treatments if at all?

 

[NysEms2117]

And what would be in such protocol beyond assess and transport?

field neurosurgery.... duh....

 

[NomadicMedic]

Ours is our pain management protocol.

Starts with Ibuprofen or APAP.
Then it's toradol or opiates.

We also have a HTN protocol, with Labetalol

 

[VFlutter]

If you are talking about migraines , as opposed to just a normal headache, then there probably isn't much you carry that will be effective anyway.

 

[VentMonkey]

Relpax does not come cheap at all.

 

[RocketMedic]

I've seen protocols in the military that actually address migraine headaches by cause. Traumatic causes = rapid evacuation, but "medical" headaches were often treated with Reglan, opiates, nsaids and even promethazine.

 

[EpiEMS]

If you are talking about migraines , as opposed to just a normal headache, then there probably isn't much you carry that will be effective anyway.

As an occasional migraine sufferer, the only things I can think of are oxygen, cold packs, and Zofran?

Starts with Ibuprofen or APAP.

PO ibuprofen & APAP?

I've seen protocols in the military that actually address migraine headaches by cause. Traumatic causes = rapid evacuation, but "medical" headaches were often treated with Reglan, opiates, nsaids and even promethazine.

AMR has a fun little DHS Austere EMS guide that identifies red flags:

1. Acute onset of “worst headache of my life” 2. Headache accompanied by persistent vomiting or projectile vomiting 3. Headache with a fever 4. Headache associated with photophobia 5. Headache accompanied by neck pain with movement or stiff neck 6. New type of severe headache in patients with Hx of migraines 7. Headache accompanied by Diastolic BP > 110 mm Hg 8. Headache accompanied by visual changes 9. Headache associated with syncope or recent head injury

They also have a protocol (PDF page 183 / listed page 177), including BLS measures like "Administer caffeine 100-200 mg PO (e.g., 1-2 cups coffee or tea), if caffeine withdrawal is the likely cause" and "Conduct urgent evacuation for a headache described as “the worst headache of my life” or an acute headache accompanied by fever, severe nausea, vomiting, mental status changes, focal neurological signs, acute onset of seizures or loss of consciousness."

I have to say, while I like a focused protocol like this, I don't think it is strictly necessary for most non-austere EMS functions - pretty basic stuff like a good history and physical exam, glucometry, stroke scale, etc. can rule in/out the life threats we focus on in EMS, no?

 

[VFlutter]

PO ibuprofen & APAP?

I highly doubt anyone is carrying IV Tylenol which is a shame since it works great.

 

[NomadicMedic]

Yes. Our protocol allows for PO pain meds, if available. We also carry Tylenol suppositories, for the kiddos.

 

[GMCmedic]

I think headache protocols require a lot of thought, probably more so than some.

I also think most places lack them because of catering to the lowest common denominator provider. Removing the hemorrhagic causes of pain, headaches/migraines can be cause by either vasoconstriction or vasodilation. Without really knowing which one it is, we may just make the headache worse with the more common medications on an ambulance.

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[VentMonkey]

We also carry Tylenol suppositories, for the kiddos.

How (in)frequently is this being utilized for febrile seizures?

 

[NomadicMedic]

How (in)frequently is this being utilized for febrile seizures?

Honestly, I may have been the only one to use it in the last year. Went to a sick kiddo, mom was overwhelmed...had NO IDEA that she needed Tylenol in the house. We also carry Diastat, and I think I may be the only one who's used that too. For some reason, people get freaked out at the PR route.

 

[RocketMedic]

The Army's looks a lot like the AMR "austere" protocol, with the caveat that our PA preferred for us to contact him via radio or phone when possible if there was much in the way of doubt as to how we got to the headache or the patient was over 40 (rare, because it was the Army). Headache after a long range in July? IV fluids, Tylenol and cooling. Headache with an established history of migraines, resistant to NSAIDs, on a long mission in Iraq? Here's some Reglan IVP and a liter of fluid. Headache after a boxing match? Congratulations, you're going to the ED.

 

[EpiEMS]

@RocketMedic Seems about right - and quite reasonable. Perks of Army medicine, you're usually (right?) dealing with healthy young folks - civilian EMS, as we all know, is a bit more variable. Do you think that AMR protocol is good enough for a civilian setting?

 

[Carlos Danger]

I don't remember ever having a protocol for headache pain in the field. But I can't really think of much reason not to. There are lots of medicines that are helpful in migraines, some of which are already commonly carried by ALS units.

Just a few weeks ago I was called to the ED for a severe migraine refractory to everything the ED could think of. She was on opioids for chronic pain.
She had a history of poor response to prochlorperazine and metoclopramide and sumatriptan. The ED had already given her 200mcg of fentanyl and ketorolac with little improvement. I offered her a sphenopalatine ganglion nerve block (which is often very effective but somewhat time consuming and requires good patient cooperation) but she was very anxious about the idea.

I considered some options and in the end I ended up giving her 5mg of versed for her anxiety, 250 mg of lidocaine IV (a little more than 2mg/kg), and some esmolol. Terminated the migraine completely.