Morphine for headaches ?

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philslat

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In our cpg's morphine is not contraindicated but is also not recommended for a headache

Does anyone know why ?

Thanks
 
philslat said:
In our cpg's morphine is not contraindicated but is also not recommended for a headache

Does anyone know why ?

Thanks
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Besides being a lousy drug? I can only speculate.... a narcotic for a h/a of unknown origin could throw off the neuro exam perhaps, the side effects of nausea and vomiting could confuse the clinical picture and make issues involving intracranial pathology more complicated...guessing. I'm sure folks can think of more. I'd pick a shorter acting, less dirty drug if I were to treat that. Fentanyl comes to mind.
 
Rebound headache. And an opiate like Morphine shouldn’t be a first line drug for a headache... there’s better meds. Unless your patient has a headache because he had an anvil dropped on him like in a roadrunner cartoon.
 
You can give this guy fentanyl... and transport to a veterinary trauma center with neurosurg because that is a nasty looking hematoma and a potentially disparate gaze

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1. MS can cause vasodilation, which could worsen headaches.
2. I'm pretty sure MS interacts with nerves of the inner ear, sometimes causing nausea -- a problem many chronic headache sufferers are already dealing with.

And yet, in some healthcare systems, opiates are third-line drugs for migraine headaches, after triptans and caffeine-related meds (e.g. ergotamine, Fioricet). As a migraine sufferer, I can tell you each of the above works sometimes.
 
I’ve used Toradol and Benadryl with success, after calling for orders.
 
Yeah, I'd be very reluctant to give, or even ask to give, morphine prehospitally for a headache. The reason I asked about protocols is that even OTC meds can be bad for patients, and I don't think I'd give even ASA for headaches unless the medical director were on board with that.
 
mgr22 said:
Yeah, I'd be very reluctant to give, or even ask to give, morphine prehospitally for a headache. The reason I asked about protocols is that even OTC meds can be bad for patients, and I don't think I'd give even ASA for headaches unless the medical director were on board with that.
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We also had APAP in our adult pain protocol, I never gave it. We didn’t carry it. And when I asked people if they took anything for their headache like Tylenol or ibuprofen they always looked at me like I had two heads. Easier to put ‘em in the truck and go to the hospital.
 
mgr22 said:
With or without a headache protocol?
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I don't think I've seen any headache-specific protocols. But that said, I would be curious to see one.
 
NomadicMedic said:
We also had APAP in our adult pain protocol, I never gave it. We didn’t carry it. And when I asked people if they took anything for their headache like Tylenol or ibuprofen they always looked at me like I had two heads. Easier to put ‘em in the truck and go to the hospital.
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Why go to [insert pharmacy here] when I can call 911?
 
There are a lot of drugs and combinations of drugs that have been known to work for headaches. Of all of them, morphine is IMO probably the worst choice.

Most headaches aren’t severe enough to warrant risking the side effects of opioids. If the headache really is that bad, I would use morphine only if I had no other options.
 
EpiEMS said:
I don't think I've seen any headache-specific protocols. But that said, I would be curious to see one.
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I've seen them under pain management. I could be wrong, but I think NomadicMedic has some experience with that.
 
EpiEMS said:
What should be the EMS go-to for headache (besides dimming the lights & an ice pack)?
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Depends on what you carry and what your protocols are (or more likely how giving med control is).

Non-migraine of benign etiology: 15 mg/kg tylenol up to 1 gram PO, 10 mg/kg motrin up to 800 mg PO or 30 mg toradol IM, PO fluids

Migraine of benign etiology (adolescent/adults):
1st line: IV fluids, 15mg tordol IV, 25-50mg benadryl IV, 10mg reglan IV (6.25-25mg phenergan IV can also be used; zofran is almost always excluded becaue of the potential of worsening headaches)
2nd line/consider adding based on history: 0.1-0.2 mg/kg ketamine over 10 minutes IV, 1.0 mg/kg (not to exceed 200 mg) lidocaine over 10 minutes IV, 2-2.5 mg haldol IV, 10 mg compazine IV

I would only give narcotics in the field in the very worst of circumstances because an physician or APP can still do trigger points for tension headaches. Narcotics are known for causing worse rebound headaches, if the must be given the longer the duration the better in the hope that they other meds that have been given will have started to work by the time that the narcotic has worn off.

Be cautious that a headache may have a more serious etiology, especially if the patient states that this is the worst headache they have ever had or do not have strong history of migraines. What appears to be a migraine could be a traumatic injury that wasn't well reported, ischemic/hemorrhagic injury, other serious vascular abnormalities, hypertensive crisis, et cetera
 
I think I've only once ever ordered an opiate for a migraine and it was a few hours in to their treatment after giving reglan, toradol, benadryl, fluids, and compazine. My experience is that reglan is a the best first line medication. Honestly, I do not think EMS should get into the habit of treating migraines in any capacity. Unless there is something else to treat, it's a BLS run.
 
medicsb said:
I think I've only once ever ordered an opiate for a migraine and it was a few hours in to their treatment after giving reglan, toradol, benadryl, fluids, and compazine. My experience is that reglan is a the best first line medication. Honestly, I do not think EMS should get into the habit of treating migraines in any capacity. Unless there is something else to treat, it's a BLS run.
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I had this just the other day. It was supportive care to the ED. I contemplated a lock, but withheld it.

The patient said that nothing they had been given up to that point had worked, however, once we got to the hospital the doc was quick to order and IV, give fluids, and push the Reglan/ Toradol/ Benadryl cocktail.

The turnaround was pretty remarkable; similar to an opiate reversal. Minutes earlier the patient had been in excruciating pain.
 
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