When It's an Emergency
Headache accounts for over 2 million emergency-room visits each year in the United States. Over half of migraineurs (54 percent) first consult their doctor about their head pain. But 16 percent initially seek help in an emergency room or urgent care setting. And over 20 percent of diagnosed migraineurs have visited an emergency facility in the past twelve months.
Emergency care is not a substitute for ongoing treatment from your doctor. Urgent care and emergency room visits for migraine should be limited to those situations in which pain is not responding to normal treatment and your provider's office is closed. These facilities are for acute care and can't provide continuous care for a chronic condition like migraine disease.
There is no current recommended standard of care for emergency-room treatment of migraine headache. Several studies have demonstrated that migraine remains underdiagnosed and undertreated in emergency care facilities. Time and resource pressures in emergency care settings probably contribute to this problem.
Your headache doctor should be your first line of defense if your migraine treatment isn't working. However, there will be times when your physician simply is not available. Before an emergency situation develops, talk to your doctor about how you should handle severe head pain that doesn't respond to treatment when it occurs after office hours. You should develop a plan that outlines what the on-call physician can do for you and what urgent care facility you will visit should the situation require it. Discuss what kind of signs and symptoms should always warrant emergency treatment.
Always seek emergency care:
If your head pain has lasted for seventy-two hours or longer without relief from standard treatments (known as
If you experience a “thunderclap” headache (an intense head pain in which maximal severity occurs immediately at the onset or within seconds of its appearance)
If you're experiencing a migraine episode that is different from any other you've had and that is causing severe, unresolved pain
If you lose consciousness during a migraine episode or experience unresolved vision loss and/or mental confusion
If your headache is accompanied by fever, rapid heart beat, or high blood pressure
If you have had a blow to the head within the seventy-two hours prior to the headache episode
If you need emergency care, make sure a family member or friend accompanies you to the hospital or urgent care center. Driving with a severe migraine can be dangerous, and it's also good to have someone with you to help keep you comfortable and to advocate for you if you're unable to express yourself clearly. Since you may be foggy from the migraine, your companion can also take down any medical instructions from the attending physician.
Ask your regular doctor to provide you with a one-page sheet of emergency treatment guidelines that specifies your diagnosis, medications, any drug allergies, and suggested pain-relief treatment for migraine episodes that don't respond to your regular preventative or abortive migraine drug regimen. Having this information at hand serves two purposes: it helps the ER staff provide you with quick and effective care, and it establishes that you aren't an addict or drugseeking patient just trying to get access to narcotics (an unfortunate reality in many emergency care facilities).
It is also helpful to have a separate page of information that contains your health insurance information, diagnosis, and the medications you've taken to treat the current migraine episode. Appendix C contains sample doctor and patient forms for your use.
The American College of Emergency Physicians (ACEP) recommends keeping a file of all insurance information, current medications (both prescription and over-the-counter), drug allergies, and pertinent medical records that you can take with you in the event of a trip to the emergency department.
Remember that emergency departments triage patients, seeing those with the most life-threatening conditions first. It isn't “first come first served.” This may mean a substantial wait before you're seen. It doesn't mean that emergency personnel are ignoring you or aren't taking your pain seriously. Most facilities will get you into an exam room where you can rest as soon as the space frees up, even if there is still a long wait ahead until a provider will be available. And they will do their best to make you comfortable in the waiting area.
The next time it's after doctor's office hours and you have a severe migraine that just won't respond to treatment, try a local urgent care center instead of the emergency department. A 2006 survey by the National Headache Foundation found that on most measures of migraine patient satisfaction, urgent care centers scored significantly higher than emergency departments. Patients who visited urgent care centers were more likely to be given a quiet place to rest while they waited for treatment, receive care in under an hour, and feel as if the treatment they received was effective.
Urgent care centers are designed as backup facilities for when your doctor is unavailable, and because they are commercial enterprises that want your repeat business and referrals, you may find an overall higher level of “customer service.” Any truly life-threatening emergency cases that visit an urgent care center will be sent on to the hospital emergency department, so the long waits involved with triaging the “sickest” patients first are usually minimal.
