JANUARY 2004 MEETING

TOPIC:  “A SURVIVOR’S GUIDE TO VISITING THE ER FOR HEADACHE RELIEF”

Have you ever had a headache so bad that you sought relief at the hospital’s Emergency Room?  Many of us have, but not always with satisfactory results.  The East Bay Headache Support Group invited Dr. Stuart B. Shikora back again to talk about what to expect when you arrive at an ER with the complaint of severe head pain.  The January 13th meeting of the East Bay Headache Support Group, held in the Hanson Room downstairs at John Muir Medical Center, was attended by 20 persons.

Dr. Shikora practices Emergency Medicine at Mt. Diablo Medical Center in Concord and Kaiser Medical Center in Walnut Creek.  He trained at Hahnemann Medical College in Philadelphia, and is board certified in both Internal Medicine and Emergency Medicine.  Dr. Shikora’s practice of Emergency Medicine covers 28 years, during which he served as Chairman of the Emergency Department and President of the Medical Staff at Mt. Diablo Medical Center.

Dr. Shikora began by stating that it had been almost 3 years since he spoke to the group the last time.  He stated he doesn’t want to alter your own doctor’s treatment, but when you have to go to the Emergency Room because of a bad headache, he just wants to help you get the relief wanted with a minimum of stress and aggravation.  Migraine headache is one of the more common reasons people present themselves at an Emergency Room for treatment.  He said that he experiences migraine headaches himself--they are infrequent and usually the visual type (flashing lights, temporary blindness, etc.).  He asked how many in the audience had experienced going to an Emergency Room with a migraine headache, and if they had bad experiences.  A number of people in the audience raised their hands.

Some problems with the Emergency Room are:

            prolonged wait

            rude behavior

            inadequate treatment

Dr. Shikora explained that many staff members have headaches also, and come to work with them.  Sometimes they try to relate their experience to the patient’s experience, but this is not good.

Dr. Shikora said that some seek pain medications for not necessarily good reasons, like to get high.  To obtain these medications they frequently complain of:

1.)  migraine headache

2.)  lower back pain

3.)  abdominal pain

4.)  toothache

This is frustrating to the Emergency Room staff.  Some have been abused by drug seekers, and they are sensitized to the fact that they may be abused again.

Dr. Shikora said that he’s never seen a sloth or a slug with a migraine.  Migraineurs tend to be intelligent, driven, ambitious, responsible, frequently compulsive.  And many will put off treatment until the very last minute.  He said that throwing up increases intracranial pressure.  You need to recognize it’s there, and change your environment so you can get the care you need (if you get a warning).

Advice given by Dr. Shikora:

1.)  Know your triggers and avoid them.  Some people’s migraines are triggered by eating chocolate, seeing flashing lights, sleeplessness, stress.  Also, any other cause of pain can trigger a migraine headache.

2.)  Seek treatment early.  Take an anti-nauseant first.  Suppositories are good if you are really bothered by nausea and vomiting.  Try taking NSAID’s (nonsteroidal anti-inflammatory drugs)--take it if it works for you.  There are 7 triptans on the market now--available in injectable form, or in nasal sprays, or pills (pills are the least effective). 

The Emergency Room staff will welcome you with open arms if you know what works for you and you ask for it, like:  “Give me an Imitrex injection.”

3.)  Rest before coming to the ER.  Dr. Shikora said that there are 35 nurses who work varying shifts in the Emergency Room at Mt. Diablo.  At least 7 to 8 of them have migraine headaches, but they have a buddy system--if one has a migraine, she/he takes 20 minutes to take a pill and rest to get better, while another covers for her/him.

4.)  Contact your doctor if at all possible.  Your doctor can call in to prescribe to any pharmacy in the state of California.

5.)  Know what you have and what you need.  If you have medical conditions besides your headache, list the conditions and what medications you’re taking.

Dr. Shikora passed out a little patient history card to each member of the audience, and advised us to fill it out and carry in our wallets.  He said Kaiser has a pink card for its members, so they can list all their conditions and medications.  If you are a Kaiser member, but present at the Emergency Room at Mt. Diablo Hospital, they can look up your Kaiser record if necessary.  And John Muir and Mt. Diablo can look up each other’s records easily.  Also, he said you should know your pharmacy’s name and phone number.

6.)  Do not doctor shop.  In the Emergency Room they are always on the lookout for people who go from doctor to doctor for medications.

Dr. Shikora said it used to be that a patient’s doctor could call the Emergency Room and tell them how to treat, but it is different now:  Have your doctor call the Emergency Room in advance of your arrival to say what usually works for you.  But Dr. Shikora always does his own evaluation of patients who present at the Emergency Room, because occasionally a headache is unusual and could be a sign of a serious problem.

How can he be certain this isn’t usual?  He takes advice, appreciates information from the personal doctor, but also does his own exam anyway.

If you can’t reach your doctor, just the covering doctor, have him/her call the ER anyway.

If you experience more than one severe headache per year, have a treatment plan written down by your doctor (on letterhead and dated), and always carry it with you.

They are trying to start a pre-authorized treatment plan between Kaiser-John Muir-Mt. Diablo.

Some patients have to visit the Emergency Room once a month, and sometimes even once a week.

Dr. Shikora said that Demerol has been phased out of Emergency Room treatment--because too many people like the euphoria that comes with taking Demerol.  Also, it can precipitate seizures in some people.

Dr. Shikora’s motto is:  “You will not leave here until you’re feeling better.”

Other drugs used in the Emergency Room are natural narcotics, like morphine; but this is likely to produce nausea.  Synthetic narcotics are less likely to cause nausea.  He said that usually an anti-nausea medication, such as phenergan, is given whenever a narcotic is given.  Phenergan is sedating.  Dr. Shikora said that if a patient is too agitated, he might give them Atavan or Valium.  And if a patient is allergic to phenergan or compazine, he might try a new anti-nauseant called Zofran.

What to do when you go to the Emergency Room:

1.)        Have someone who can drive you home.

2.)        Bring whatever works to keep you calm while you have to wait

(headset with CD’s, dark glasses, etc.).

3.)        Understand you will be treated.

4.)        Bring a letter or card from your doctor.

Dr. Shikora then talked about various medications used to treat headaches.  He said there are 6 pain management specialists at Mt. Diablo, and lots of others in the area.  A large number of patients are on methadone, a suppressive medication for pain.  But patients on methadone should be taking other medications when they’re pain breaks through.  These are needed on top of the methadone for pain.

Dr. Shikora made the statement that the undertreatment of pain is a national scandal--for cancer patients and headache patients.  He said that doctors are now required to take 20 hours of training in pain management. 

Dr. Shikora frequently uses Stadol nasal spray for a headache patient in the Emergency Room.  He said it is “great stuff” but that it produces a euphoria and is habituating so patients have to be very careful with it.

He said there is no one set formula for treating headaches--no magic bullet yet.  Some patients can tolerate side effects from these medications, while others cannot.  For people who’ve had headaches before, they know that however bad it is, it will end (no matter what they do).  But Dr. Shikora said it will end sooner if you get treatment.

Besides taking pain medications, adjunctive treatment can help, such as exercise, listening to soothing music, and eating correct foods.

Dr. Shikora talked about the exam needed when you come to the Emergency Room complaining of head pain.  The ER doctor needs to know your normal pattern.  If this headache is different than normal, tell the doctor.  He said that not all migraines first begin in youth.  His mother-in-law had her first migraine headache at the age of 58.

The usual practice of an Emergency Room doctor is to send a note to your doctor, especially if you ask them.  He said you need to always carry your doctor’s card in your wallet.

Also, if there is someone that you don’t want to be notified, you must tell the ER doctor.  We now have a Health Information Privacy Act, but you have to be proactive to suppress them from sharing information with your other doctors.

An audience member asked Dr. Shikora, “Do you give Imitrex as injections or in pill form in the ER?”  He responded that the Emergency Room only has Imitrex available as  injections, and also that Imitrex is the only injectable triptan.

Another person asked how often it is safe to take Imitrex--only twice per week as she was told by her doctor?  Dr. Shikora advised her to go back to her doctor to discuss how often she can take it.  He added that it is important that you take your triptan as soon as you feel the migraine coming on.  Don’t wait.

Dr. Michael Stein, the medical advisor for the East Bay Support Group, was in the audience.  He told Dr. Shikora and the group that it is possible to give a patient less than 6 milligrams (the standard dosage).  He said smaller amounts can be drawn up from the ampules.  Dr. Shikora said that was useful information for him, and that he will now give less than 6 milligrams if he feels that is right for a particular patient. 

Dr. Shikora mentioned that he’s even used Imitrex for someone in the ER complaining of back pain.  He said this is one less narcotic he can use for pain relief.

Dr. Shikora asked the audience for information that he could take back to his Emergency Room.  He said they are aggressively developing a plan to coordinate care of patients, and he would love to know what we’d like them to know.

Dr. Stein said that some patients receive numerous CAT scans when they present at the Emergency Room.  Dr. Shikora responded that he orders a CAT scan if he thinks a patient’s headache is a significant change from their usual pattern of headaches.  They are not meant to be punitive.  The magic words that scare an Emergency Room doctor are “worst pain in my life” and “sudden onset.”  Then he needs to look for a subarachnoid hemorrhage.

He said it is helpful for you to keep track of your CAT scans and MRI’s (keep a copy).  And he added that you should keep your own medical file (he does), especially if you travel.  Dr. Shikora said that when someone comes to the Emergency Room carrying a list of their doctors, medications, discharge summary, it’s really helpful.

When Dr. Shikora sees a headache patient in the ER, he will ask if the headache is otherwise the same, and ask the patient what works for him.  He said the patient’s experience is the greatest source.

He asks the patient to rate his pain using the Pain Scale 0-10, in an effort to semi-quantify the pain.  The worst pain would be a 10 and no pain is 0.  The doctor or nurse should ask you, “What’s manageable for you?  Maybe taking it down to a 3 from a 9?”

Dr. Shikora was asked if he would give someone more than the manufacturer’s recommendations?  He said that if you find that you typically need a larger dose of a medication than what is recommended, that you carry a note from your doctor indicating this. 

Dr. Shikora talked about the Pain Management Center at Stanford, where they have 5 beds for patients in chronic pain.  They are put on a gurney for a day and given whopping doses of medications in an attempt to tailor their therapy to what they actually need.

He said the goal of an Emergency Room doctor is not to get his patients to be just pain free, but better functioning.

The intention of the East Bay Headache Support Group is to provide information and resources.  It does not provide medical advice, which should be obtained directly from a physician.