Headache protocol

[EpiEMS]

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.

If those meds are already on the, say, pain management protocol, is there a need to have a separate protocol? Of course, if they're not (maybe I'm revealing my lack of knowledge here, but perhaps, IV lidocaine could be one), then I see the point, certainly!

 

[VentMonkey]

@EpiEMS can we add it to a protocol? Sure, but this means building said protocol, training "X" amount of paramedics, and getting them up to speed.

Sometimes what we have should suffice, so the standard pain management protocol with some Zofran thrown in seems sufficient for our general level of expertise, and training. If there are no changes with the appropriate aliquots, and the paramedic feels like trying to pitch IV Lido to an EM attending or MICN for migraine management, I guess, but sometimes I think we need to know when we're in above our heads.

Having to call a CRNA down for special medications after the treating physicians options had been exhausted tells me how much more training, and infrequent (at least prehospital-wise) of a true problem worthy of its own protocol this seems to be.

There are many other areas that we are lacking in than to just jump to arbitrary headache protocols, unless perhaps the population served is generally at a higher-risk than others of such. I'm all for progress and pain relief, but some training will be forever above our knowledge-base and that is not a deal-breaker, nor hardly representative of what I am capable of.

 

[Carlos Danger]

I guess my point was that having a protocol specific to migraine or cluster headache pain probably isn't the worst idea, nor would it be the hardest protocol to write and it wouldn't require carrying new drugs that have no other uses.

Headache pain can be really, really severe. And it generally isn't well managed by opioids, which is the mainstay of most analgesia protocols. However, there are other management approaches - some which are well established (like reglan and compazine) and others which are fairly novel (like lidocaine and esmolol) but do work in at least some cases.

Some literature says that propofol works well, but I have yet to try it.

 

[RocketMedic]

@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?

I do. I think that most of the realistic treatment options for migraines functionally involve transport to a hospital, and with the exception of NSAIDs, few of them are really dangerous in the worst-case scenario. With age controls installed, I think that the AMR protocol is wholly acceptable.

 

[Tigger]

We are hoping to develop a migraine guideline and expand the formulary as such. Our medical director provided some research showing that opiates will increase rebound issues with migraines.

 

[EpiEMS]

can we add it to a protocol? Sure, but this means building said protocol, training "X" amount of paramedics, and getting them up to speed.

Absolutely true. And I don't disagree - because it is relatively infrequent (and often can be managed by what we've got already), it may not always justify a new protocol. Of course, I'm not wholly averse to a new protocol, and I think your caution is warranted.

 

[VentMonkey]

I should add that though it's been mentioned before, it's true that there's so much more we can do/ focus on than just the "cool stuff".

I just can't help but ponder where this leaves us in terms of protocols, training, and the like.

Clinical-wise where should we focus more? We can hardly provide basic airway management half of the time, and (generally speaking) our advanced skills aren't a whole lot better. Would tacking on more protocols really be something worth exploring when we can hardly provide the fundamentals consistently efficient?

 

[EpiEMS]

@VentMonkey, hear hear!

 

[NPO]

Headache protocol: Assess, monitor, transport.

Enter other algorithms as appropriate.

Sent from my Pixel XL using Tapatalk

 

[aquabear]

We are hoping to develop a migraine guideline and expand the formulary as such. Our medical director provided some research showing that opiates will increase rebound issues with migraines.

We have an atraumatic headache/migraine protocol and in my experience it works pretty well.

 

[rescue1]

With the exception of rural agencies with very long transport times, I really can't see the need for a headache protocol more advanced than NSAIDS or other similar OTC medications, plus the considerations to rule out stroke and trauma. For those with a long transport time or feeling particularly creative, something like nitrous oxide has some (small) evidence behind it in migraine treatment, is already carried by EMS agencies, and is also useful for other painful conditions.

Besides, as VentMonkey points out, most EMS agencies still struggle with optimizing basic emergency care (mine certainly does). I feel like sometimes EMS (and sometimes other healthcare workers, to be fair) see growth as a profession in terms of acquiring new skills and medication access as opposed to being really good at their specific craft.

 

[SpecialK]

What about a list of risk factors or more untoward presentations that could enable appropriate referral management?

 

[EMS4Life1982]

Well I guess it depends on the needs of the organization rather a protocol is necessary.