Headache Patients in Urgent Care or ER — A Response

I often hear from my colleagues who work in the emergency room or urgent care how they hate seeing headache patients there because it is so “inappropriate.”  I had such a statement from a ER medical provider on a private Internet forum last night and below is my response to them:

So if an epilepsy patient is followed by an epileptologist with good management, however, suddenly has a seizure and goes into status . . . he/she should not go into an acute setting for help? 

We give our headache patients great chronic management, great tools to use at home, yet even with that, they may require compassionate urgent treatment that they can’t do at home. I think urgent care people (and I have worked in both urgent care and ER myself) have been jaded because of all the headache patients with extremely poor chronic management that come in as their main source of treatment. 

At Mayo we had a 24-7 urgent infusion center for headache patients who had failed all their available treatments. I spoke to a headache specialist yesterday who is part of a university center, but has decided to do full time “Headache Urgent Care” and as set up such a clinic. 

Headache disorders are the most discriminated disorders in our society because of the Victorian concept that they are not real or a sign of personal failure, “stress” or weakness when in reality they are no different than epilepsy.  I have about one patient per year who dies directly from the fact that they suffer so much from chronic migraine, which is intractable (as 20% are).

I have a patient that I have followed for 7-8 years. When we started, she was disabled with chronic migraine, with level 8-9/10 daily with nausea and vomiting. We have tried about 20 different chronic medication combinations as well as several procedures.  She is 70% better. For rescue, she has, at home, 4-ketorolac IM injections/month, 4 hydromorphone suppositories/month, as well as dihydroergotamine injections. However, about once every 2 months she gets into a status migraine that can last days with severe nausea and vomiting and dehydration. So she goes to her ER 3-4 times a year, when it use to be once a week. however, each time she goes in, the ER doc calls me and starts to argue in anger how inappropriate it is for her to be in “his ER” and I have to “keep her out.”  Every headache specialists in the US would support that what she is doing is exactly correct and that there is nothing else that can be done.

I would offer 24-7 urgent care but I already spend 10-12 hours in my clinic every day, working 2-4 hours on each day of the weekend and cannot work 24-7 because I have to sleep sometimes and eat and go potty.

So if you ever see a headache patient in an urgent care setting, especially a frequent flyer, who is not under the care of a headache specialist (neurologists don’t count) then make sure they are. But if they are getting excellent care and still go into a headache crisis, they need to be treated with respect, exactly the same as someone with an open fracture. The pain of a serve migraine can be worse than an open fracture, renal calculi, stab wound and etc. and it can be as deadly if untreated.  J. Michael Jones, MAPS-C