Are you giving poor care to migraine patients?

Many EDs undertreat headache pain

Over a two-year period, a 39-year-old woman came to Richmond-based Virginia Commonwealth University Medical Center’s ED more than 100 times for treatment of migraines, and each time she insisted that specific narcotics be given, reports Denise Sullivan-Wade, BSN, RN, the ED’s case manager.

The patient was encouraged to seek care in a less acute setting to ensure consistent treatment, but the woman instead chose to continue seeking care at a variety of EDs, says Sullivan-Wade. "This disjointed ED care can lead only to frustration and migraines that never are controlled," she says.

Sound familiar? Unfortunately, this scenario is commonplace, and spotlights the unique challenges of caring for migraine patients in the ED, says Sullivan-Wade. In fact, when Sullivan-Wade sought care at an ED for her own severe migraine, she didn’t receive relief from her pain and, instead, endured a lumbar puncture to rule out life-threatening causes. "I went home with the migraine still present — and a new pain from so many needlesticks to my back," she says.

ED nurses at McKay-Dee Hospital Center in Ogden, UT, treat more than 100 headache patients each month, reports Kayleen L. Paul, RN, BS, CEN, care center director for emergency, critical care, and trauma services. "Headache is one of our top five diagnoses for discharged patients," she says. "The staff estimates that 80%-90% of those are migraine patients."

To improve care of patients with migraine headaches, do the following:

• Use current approaches for migraines.

Migraine patients may be treated with intravenous fluids, promethazine, prochlorperazine, butorphanol tartrate, or some other combination of drugs, says Paul. Here are the steps that occur when an ED patient presents with a complaint of headache:

  • A triage nurse evaluates the patient, and the patient is escorted to a room, where the patient care nurse evaluates onset, description, triggers, and assessment with use of a pain score.
  • The nurse initiates comfort measures, such as darkening the room, applying warm or cold packs, and controlling noise as much as possible.
  • After the physician examines the patient and diagnostic testing is completed, the nurse administers any medications and evaluates the patient’s response.

"For migraines, the aim is to start pain relief, not necessarily get the patient pain-free before discharge," Paul explains.

• Improve the way you manage pain.

Recent patient satisfaction surveys revealed dissatisfaction with the way headache pain was managed in the ED, reports Paul. "Although the nurse often had charted comfort measures for these patients, the perception of the patient was that little had been done," she says.

Charts were reviewed for patients with chest pain, fracture pain, abdominal pain, and headache to ascertain which type of pain was addressed fastest and most thoroughly. "As you might imagine, chest pain and fracture pain were treated most quickly, then abdominal pain, then, last by a long shot, headache," says Paul.

The audits showed that chest pain and fracture pain were addressed within minutes and abdominal pain usually was medicated within an hour, but headache pain often took even longer.

In addition, headache patients often received fewer or lower doses of pain medications, says Paul. "It seemed that headache somehow wasn’t as valid or believable as the other sorts of pain," she says.

ED nurses now make a concentrated effort to reduce head pain by consistently performing comfort measures, such as lowering the lights, placing patients in a quiet room, and using pain scales to monitor response to interventions.

"We discuss application of warm or cold compresses and how that might mitigate pain, and sometimes we even experiment to see which works best," says Paul.

As a result of these changes, the ED’s scores for the survey question, "How well was your pain controlled?" increased to a score of more than four in a numeric scale rating one as poor and five as excellent, Paul reports.

• Teach patients to control their own headache pain.

When headache patients are discharged, ED nurses now include a brief discussion of headache triggers and ergonomic factors affecting tension headaches, says Paul. Nurses teach patients to mitigate or prevent headaches with massage; warm or cold packs; light and noise control; avoidance of alcohol, tobacco, and caffeine; stress reduction techniques; ergonomics; sufficient sleep; and over-the-counter pain medications. "One of the ED nurse’s most important roles is to teach the patient about ways she can prevent or mitigate the headache pain," says Paul.

• Take pain reports seriously.

Often, migraine patients are labeled wrongly as chronic pain medication seekers, notes Sullivan-Wade. "While the ED is most certainly the place to go for emergent exacerbation of migraine, multiple visits may give nurses a negative view of the patient’s motivation for seeking treatment," she says.

Give migraine patients an individualized plan of care, advises Sullivan-Wade. "Our goal is to have ED visits occur only for severe, acute exacerbations, which should be infrequent if the migraine is properly managed," she says. "Otherwise, they are at high risk for overdose and have no continuity of care. The results can be devastating."


For more information about treatment of headaches in the ED, contact:

  • Kayleen L. Paul, RN, BS, CEN, Care Center Director, Emergency, Critical Care, and Trauma Services, McKay-Dee Hospital Center, 4401 Harrison Blvd., Ogden, UT 84403. Telephone: (801) 387-7006. Fax: (801) 387-7038. E-mail:
  • Denise Sullivan-Wade, BSN, RN, Emergency Department, Case Manager/Liaison, Virginia Commonwealth University Medical Center, Department of Emergency Medicine, Medical College of Virginia Campus, 401 N. 12th St., P.O. Box 980401, Richmond, VA 23298-0401. Telephone: (804) 628-0801. Fax: (804) 628-0488. E-mail: