TRANSCRIPT:

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Voice-over: Welcome to Spotlight on Migraine, hosted by the Association of Migraine Disorders. Join us for fresh perspectives by medical experts and advocates as we explore the spectrum of migraine and dig deeper into this complex disease.

This episode is brought to you in part by our generous sponsors Amgen and Novartis.

Molly O’Brien: Hi there, and welcome to Spotlight on Migraine. I’m your host, Molly O’Brien. Today we’re talking all about migraine in the emergency room. To help us navigate this topic is Dr. Alyson McGregor. She’s the cofounder and director of Sex and Gender in Emergency Medicine at Brown University’s Department of Emergency Medicine. Dr. McGregor, thanks so much for joining us.

Dr. Alyson McGregor: Thank you for having me. This is terrific.

Molly: I’m super excited to talk about this topic. We also want to mention that Dr. McGregor is an AMD specialty board representative and she has a new book out that sounds fascinating. Hopefully, we can dive into it another time. It’s called Sex Matters: How Male-centric Medicine Endangers Women’s Health and What We Can Do about It. Again, I hope we can talk about your book at another time, because it sounds fascinating.

Dr. McGregor: I would love to. I would love to.

Molly: Wonderful. Well, again, thank you so much for joining us. We’re going to talk about navigating and managing migraine in the emergency room. I kind of want to talk about this from different perspectives — not only the patient perspective, but from the provider perspective. Get some insight from you as well. 

So I know a lot of people with migraine want to avoid the ER because it’s tough. There can be a lot of challenges there. So it can be a difficult decision to make your way to the ER. Can you tell us about some of the troubles or challenges that migraine patients might face if they need to go to the emergency room?

Dr. McGregor: Absolutely. The emergency room is an environment that is not under the patient’s control many times, especially someone suffering from a migraine headache. And it’s very well lit, with lots of fluorescent lights in the emergency department. It’s very bright no matter what time of day. It can be very noisy. There’s a lot of stimulation. Oftentimes, there’s a long waiting time and you have to sit in a waiting room, waiting to be cared for, and you don’t feel well. And so that is a big challenge to seeking care for something like migraine in the emergency department.

Also, it’s a very costly way to receive medical care. It’s more expensive to receive care in an emergency department than, say, a clinic or primary care doctor. So depending on insurance status and things like that, I think those are challenges that many patients have to weigh out before they decide to go.

Molly: That’s an excellent way to put it, I think, “weigh out,” which oftentimes migraine patients do: “Look, is this attack that I’m having worth spending this amount of money?” It’s difficult, but sometimes you need to make those tough decisions.

Dr. McGregor: Yeah, and we hope that patients do feel comfortable enough to come in if they need to be seen instead of suffering at home. I think that it’s important for them to feel as though that they have access to care 24 hours a day, 7 days a week, and that’s really what the emergency department is there for.

Molly: Thank you for that. I kind of want to flip that question on its head now. We did talk about what patients can face and what challenges they might face if they are seeking treatment for migraine in the emergency room. I’m curious what challenges medical professionals face when they are presented with someone who either has migraine — a diagnosis — or is presenting symptoms that are classic migraine. 

Dr. McGregor: A lot of the challenges that providers face is that most of the time, by the time a patient comes to the emergency department with a migraine headache, they’ve already tried a lot of other medications and other modalities that they have of decreasing stimulation and avoiding their triggers. So it’s challenging because you have to sort of find out what they’ve done so far and then try to see if there’s other things that we can offer from the emergency department perspective. 

So there’s that, and there’s also the challenge of managing expectations, ensuring that the patient knows that they may not become pain free by visiting the emergency department, but hopefully we’re able to stop the pain cycle, at least — provide enough relief that they can feel as though they can go home and sleep, or to drink, because maybe they’ve been so nauseous. So I think managing expectations and then realizing that it’s challenging because many of them have already tried lots of different medications.

Molly: That’s a great point. I think managing expectations is crucial because it’s not an end-all be-all; it’s not a one-size-fits-all cure for people, if you head in the emergency room, then it’s going to be gone like that. So I think that’s a great point.

So, Dr. McGregor, this is kind of a broad question, and I know everyone’s experience will be different, but if someone is headed into the emergency room for treatment of migraine, what can they expect? Is there any kind of general overview that you can give us?

Dr. McGregor: Well, first, just arriving at an emergency department, you’re in the waiting room and you’ll be greeted by a triage nurse. And then once they check your vitals and discover why you’re seeking care, you will then sit in the waiting room and hopefully not for long, but you never know. And then at some point you’ll have a room where another nurse will then greet you and you’ll be in your treatment area, and then you’ll see a healthcare provider after that.

Now, depending on where you go, that could be a advanced practice provider, like a nurse practitioner or a physician assistant, or it could be a physician. If you’re in a teaching hospital, keep in mind that you may be interviewed by a medical student, also have a resident physician, and then the supervising attending physician. So you do have to tell your story multiple times, and I know that that can be very frustrating, especially when you’re not feeling well. 

So if that’s the case, you could always make sure that you at least communicate the main concerns that you have, get the treatment started, and then the physician or the healthcare provider can always swing back when you’re feeling better and sort of fill in some of the blanks.

Molly: That’s some great insight there, that you might have to tell your story a few times. Now kind of continuing off of that question, if someone heads into the ER for migraine treatment — and, again, everyone’s different — but what are some standard treatment options and diagnostics that physicians might run?

Dr. McGregor: So even before we start that, it’s important for an emergency physician to understand the diagnosis. So if a patient comes in and says, “This is my migraine headache, and it’s very similar to how my migraines are,” I would often ask them, “How did you come up with that diagnosis? Was that through your primary care doctor, or are you under the care of a specialist or a neurologist?” because many patients will just assume that that’s the cause of their headache. 

And so as emergency physicians, we are so trained to think broadly. And so is this a migraine that’s the cause of the headache, or is it trauma or stroke or infection or all these other things? So if we think that that may be part of what we need to rule out, then we might order blood tests or other imaging studies. So I think that if you have a history of any of those documented, it’s important to bring that with you so we can sort of move from that sort of space forward. 

If it is considered that this is your normal migraine and it’s just severe, then the treatments would mostly include IV medications because most of the time patients feel nauseous or are now vomiting. So even just IV fluid hydration can really help turn around a patient. Other options are things like nonsteroidals like Toradol, IV Benadryl, some abortive therapies like sumatriptans, maybe some magnesium through the IV, or some steroids. 

And, again, the reason why it is important to also know about your medical history is so that the physician knows if there are any sort of contraindications to any of those medications. There’s a whole list of medications that we can provide, but we want to make sure that we understand what medications you’re already on, what you’ve taken so far already, especially that day of, and how many, and that sort of thing. So making sure that you keep track of all of your medical history is very important, and then you can have this conversation with the healthcare provider about what might be beneficial to get started.

Molly: It’s so challenging — I’ve lived with migraine my whole life — to think about going into that setting and having to advocate for myself and talk about my symptoms and that kind of thing. But on the flip side, looking at it from a healthcare provider’s point of view, especially in the emergency room, I can’t imagine how difficult it must be to try to narrow it down. So if someone has migraine, it seems like, OK, that might help a little bit. But if someone’s coming in, they don’t know what migraine is, they’ve never had an attack, I mean, then you’re looking at it from a whole other perspective because you’d need to narrow that stuff down. It sounds like a real challenge.

Dr. McGregor: It is, and it’s one of the reasons why those that go into emergency medicine love it so much, because we get to diagnose many conditions and we get to really think about what the possibilities are for when a patient comes in with different complaints. So I know that a lot of the people with migraine tend to have it chronically, and so that’s helpful. So when a patient says, “This is my typical migraine,” that’s very helpful, and we can sort of work from there. 

But if it’s not, it’s important to really sort of describe the symptoms, that you think it’s migraine, but you’re not sure. It’s different. It’s more severe. It was sudden. If you have any other symptoms, that’s really important to discuss with the physician as well.

Molly: I like that you explain that if someone’s working in the emergency room or in emergency medicine, that’s what they like to do. It’s a challenge to figure that out. So that’s a nice way to think of it is that you want to get to the bottom of it. I like that.

So you mentioned a couple things that patients can do, like make sure they have an idea of their symptoms, what medications they’ve already taken. Do you have any other suggestions that migraine patients can follow to better advocate for themselves within the emergency room?

Dr. McGregor: I do think that it’s important to also have an advocate, and I say this for any condition, really. It’s challenging right now with the COVID-19 pandemic because you can’t really have visitors, but you can still provide someone that we could call if you feel as though you can’t really speak up for yourself. Or if you’re in too much pain, or if you feel like you’re not being treated adequately, then you have an advocate there that can say, “This is really painful for them,” or, “This is unlike what they normally suffer from,” or, “They wouldn’t be there if they didn’t need to be.” So I think that having someone else to call is often helpful.

Also providing feedback to your healthcare provider that this is not working or that felt good. A lot of people use pain scales, so if you come in and you say your pain is 8 out of 10, then it’s important to say, well, after that particular medication or the fluids, OK, now you’re a 6. And it’s like, OK, now we’re working together. You should look at your healthcare provider as a very well-educated consultant in your care, so not necessarily a specific dictator. So that’s why I like to empower patients to feel as though they can take part in their own healthcare advocacy.

Molly: I love that: your provider, your physician, is a very well-educated consultant. That’s such a different way to think about it from the patient perspective, which I think is awesome, rather than this is what says go. Work together as a team — that’s great.

Dr. McGregor: Yeah, thank you. I think that now with the access, also, to so much information on the Internet, that many patients are coming in informed, and they should be very comfortable discussing that. They can say, “I heard about this new treatment. Is that available for me now?” or, “I think I might have this because I read this on the Internet.” That way there’s a conversation. Your consultant is on your team.

Molly: Excellent strategies there. And, Dr. McGregor, you did mention the COVID-19 pandemic. People aren’t allowed to have someone physically there with them in the emergency room. Every situation’s different. But I’m wondering if you can tell us at all how the COVID-19 pandemic has impacted migraine specifically within emergency medicine.

Dr. McGregor: In general, I feel as though many patients are avoiding coming to the emergency department because they feel as though they don’t want to be in a crowded area. They will be with other sick people and possibly become exposed to COVID-19. And so what I’m finding is that people that are suffering from migraines are staying home longer and are in worse shape by the time they actually do arrive in the emergency department.

Also, they’re having less access to their primary care doctors or to their specialists. Many of those offices are only seeing people virtually, and many of the appointments are being canceled. And so I’m finding that there’s this lack of access to care that a lot of people with migraine are experiencing based on this pandemic.

Molly: It’s all amazing insight that you’re giving us here today, and it is curious to see how the COVID-19 pandemic is impacting all different areas of medicine. So thank you for sharing that with us.

Now, this is, again, kind of a broad question because everyone presents differently, but I’m wondering if you might be able to tell us, if someone does have migraine, when is it absolutely necessary to visit the ER? It’s a difficult decision. Now we’re factoring COVID-19 into it. Is there any certain types of symptoms that migraine patients should be aware of if they’re making a very tough decision to visit the ER?

Dr. McGregor: That’s a really important question because even people who suffer from chronic migraines may also have something else going on if they have a headache. And so if there’s any change to it that you’re not used to — you get any neurologic symptoms like either weakness or tingling, if it’s sudden and severe, or if you have any other symptoms like fever and that sort of thing. So that’s the first most important step is if you feel as though it could be something else that’s concerning, then definitely don’t hesitate.

If it’s your normal migraine and you just feel as though that you’re dehydrated, it’s very hard to get better when your body is dehydrated. How do you know if you’re dehydrated? If you’ve been vomiting or if you’re very nauseous and you haven’t been able to keep any food or drink down, then I think that that is something where it’s time, especially if it’s been several days, it’s time to go to the emergency department and get treated with IV medications. Even that alone can do wonders.

Molly: Again, excellent advice and insight there. So we really appreciate having you. If you’re up for it, we have a few questions from our followers out there.

Dr. McGregor: Go for it.

Molly: OK, wonderful. So one of our followers wants to know, “Is there a good way to approach the issue when a patient feels like they’re being treated poorly in the ER or if it feels like the staff might be treating them as though they are a ‘drug seeker’?”

Dr. McGregor: Yeah, that is challenging from both a patient and a provider perspective, for sure. We used to treat migraines with opiates, and now we realize that there’s been research done that shows that it’s not that effective in aborting a migraine. Also, there’s clearly the now concern for it being an addictive substance. So we’re weighing out those factors very carefully. 

If you are someone with migraines that are normally treated with pain medication like an opiate or a controlled substance — and sometimes that is a very effective, necessary treatment plan — but it has to be something where you have an established relationship with a doctor, a provider, a specialist. And that sort of lets us know that you’re under the care of someone who’s watching your usage and making sure that it’s not anything to be too concerned about.

We do have something called the Prescription Monitoring Program in the US, where if you are prescribed and you pick up from the pharmacy any controlled substance, we can actually look at that online. And if your prescriber is the same doctor and you go to the same pharmacy, then we feel as though you’re safe, you’re under this particular care. 

If you have a lot of different prescriptions from various urgent-care centers or EDs or different pharmacies, it would be more challenging for us to be able to use that to treat you because of all the restrictions that we’re given now. So we’re sort of weighing the fact that research shows that it’s not that helpful, and then we don’t want to contribute to any sort of addiction problems.

But, again, a conversation with your doctor is always helpful. So if you feel as though you’re being sort of — there’s been some bias against you that seems to not be warranted, speak up. I mean, that’s an easy conversation to have with your doctor. Say, “I feel as though you think that I’m here for pain medication and drug seeking, and this is a concern to me.” And so we have those conversations frequently.

Molly: And that’s a tough question to answer. I think it’s a tough question to ask as well. But it sounds like there’s enough evidence in place, and now there’s new steps and methods so that that shouldn’t be a question that’s happening anymore. That’s what it sounds like, that it shouldn’t be as much of an issue maybe five, ten years down the road from now.

Dr. McGregor: Yes, we’re hoping. I mean, I think that we have so many other options. There’s a whole toolbox of medications. So I would also suggest to patients that they be open-minded to trying alternative treatment plans, and I think that if at the end you’re still in too much pain, then that would be the time to have that discussion.

Molly: Wonderful. So this is a fascinating question, I think, from one of our followers. We talked about the waiting room in emergency medicine, and that can be really difficult. So this person wants to know, “Would taking an ambulance to the ER be better than having someone drive you?” They want to know if it could help someone be seen faster and avoid that waiting room.

Dr. McGregor: I love that question. No, your transportation to the emergency department does not factor into how quickly you get seen. Both the ambulance waiting room and the walk-in waiting room, they will get your vital signs, they’ll talk to you about your symptoms, and then you are assigned a sort of triage level, and that is based on how quickly they think that you need to be seen. 

So, no. We even had someone register in the walk-in waiting room and then saw the line and then went down the street, called the ambulance, and then took the ambulance in. And it’s just an expensive transportation system. So, no, unfortunately, it’s all based on acuity.

Molly: Thank you for setting the record straight on that one. OK, so our last question from followers out there — want to know if providers need to or should consult with the patient’s neurologist, if they have one, before deciding on a treatment method when they’re in the emergency room.

Dr. McGregor: It’s certainly not necessary, but it can be very helpful. So if you do have a neurologist, we’d be happy to call them and discuss your care specifically because they’ll know you more than we; we’re meeting for the first time, most of the time. So any sort of additional information and other doctors, we find very helpful. 

Keep in mind office hours. So, most of the time, we are quite busy in the evenings and overnights, and that’s because most of people’s physicians are at home sleeping. And so if it’s during daylight hours, we’re happy to give a call. And even if it’s not, and the office is closed, we can usually call the on-call doctor and let them know at least you were seen in the emergency department and give some basic information so that you have good, close follow-up.

Molly: Wonderful. Well, Dr. McGregor, thank you so much for joining us here today on Spotlight on Migraine. It’s been a pleasure speaking with you. I know I learned a lot, and I’m sure our followers did as well, so we really appreciate your time.

Dr. McGregor: Thank you, Molly. This was really enjoyable as well, and I hope to look forward to speaking with you again.

Molly: I do as well. Well, thank you, everyone out there, for watching this episode of Spotlight on Migraine. Again, I’d like to thank our guest today, Dr. Alyson McGregor, and from the Association of Migraine Disorders, I’m Molly O’Brien, and we’ll see you next time.

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Voice-over: Thank you for tuning in to Spotlight on Migraine. For more information on migraine disease, please visit MigraineDisorders.org.

*The contents of this podcast are intended for general informational purposes only and do not constitute professional medical advice, diagnosis, or treatment. Always seek the advice of a physician or other qualified health provider with any questions you may have regarding a medical condition. The speaker does not recommend or endorse any specific course of treatment, products, procedures, opinions, or other information that may be mentioned. Reliance on any information provided by this content is solely at your own risk.