A 53-year-old woman with a history of recurrent migraines presents to urgent care with a severe headache. She reports a history of 4 headache days per week, which has been going on for more than 10 years. She typically manages her headaches with oral eletriptan, naproxen, acetaminophen, and a combination butalbital/acetaminophen/caffeine drug. In the past she has been treated with botulinum toxin injections and oral topiramate. She typically presents to the ED or an urgent care 3 times per year for management of severe headache, but because she has previously experienced dystonic reactions, she is reluctant to receive an antidopaminergic medication. As you begin your evaluation, she says, “Doc, just give me my hydromorphone.”
What is the best next step in managing this patient?
- Perform both a bilateral greater occipital nerve block and a bilateral sphenopalatine ganglion nerve block and refer her for neurology follow-up.
- Give her 4 mg of hydromorphone as she requested; after all, she knows what works for her.
- Slowly infuse IV metoclopramide 10 mg and IV midazolam 2 mg.
- Attempt to relieve her pain with nonpharmacologic treatments by using oxygen 10 L/min for 20 minutes and 10 mL/kg IV normal saline bolus.
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Answer: a. Perform both a bilateral greater occipital nerve block and a bilateral sphenopalatine ganglion nerve block and refer her for neurology follow-up.
You saw that your patient was in severe pain, but you wondered whether giving her opioids was the best option. This patient met criteria for chronic migraine because she experienced headaches more days than not. You performed bilateral greater occipital nerve blocks, using a total of 6 mL of 0.5% bupivacaine to block both her right and left greater occipital nerves. You also performed bilateral sphenopalatine ganglion blocks by administering 3 mL of 0.5% bupivacaine into each naris. You referred this patient to a neurologist, with noted concern about her use of butalbital, acetaminophen, and caffeine (BAC), which can cause rebound headaches. She saw the neurologist for follow-up, and he transitioned her off the BAC and restarted daily oral topiramate 25 mg for headache prevention and oral eletriptan 40 mg to be used not more than twice weekly.
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Tracey Davidoff, MD, FACP, FCUCM, has practiced Urgent Care Medicine for more than 15 years. She is Board Certified in Internal Medicine. Dr. Davidoff is a member of the Board of Directors of the Urgent Care Association and serves as Co-Editor-in-Chief of the College of Urgent Care Medicine’s “Urgent Caring” publication. She is also the Vice President of the Southeast Regional Urgent Care Association and a member of the editorial board of the Journal of Urgent Care Medicine. At EB Medicine, Dr Davidoff is Editor-In-Chief of Evidence-Based Urgent Care, and co-host of the Urgentology podcast.
