A 24 yo male with chronic migraines, presents to your ED with status migrainosus for 72 hours. He has tried his home therapy of ibuprofen, tylenol and a triptan. After throwing in some iv fluids, prochlorperazine and dexamethasone, his headache remains a 10/10. He is followed by neurology, has had a recent head MRI, and this feels like his usual migraine.
What traditional options are we left with for treating this headache?
So this kinda sucks.
Fortunately, this patient presented five shifts into my new role as ER attending physician, and wearing my freshly minted scrubs, I am presented with the perfect opportunity to try some novel migraine therapies.
The fantastic folks over at Academic Life in EM (ALiEM) recently covered the literature on the use of propofol for migraine headache, and I will direct you there for the background/evidence. It is a brief post, so check it out before reading further.
To summarize, small aliquots of propofol (10-30 mg) every 3-5 minutes have some potential benefit for refractory migraineurs.
After trying this for my patient, I was left with many questions, notably:
1)Is the time commitment feasible or reasonable?
The average time of sedation in this paper was 30 minutes, with the stop point being one hour. In the second paper discussed, VAS pain scores were measured from 0-45 minutes.
One hour is a long time to take with a trauma patient you are resuscitating, let alone a patient with a headache. Moreover, that does not include set-up, consenting the patient, monitoring post-procedure, etc. which adds to the procedure time. In my case, I treated this like any other procedural sedation, mostly because this isn’t something ever done where I work, and I’m the new guy.
2)What is the ideal depth of sedation?
In the papers on this subject, light sedation is the target, and patients are generally speaking throughout the procedure. In Krusz’s paper, a few of the patients developed drowsiness or transient slurred speech. In my case, a bit of drowsiness but no more than that.
One of the key arguments for propofol use is to get the patient some sleep and break the pain cycle. This raises the question of “Why not give slightly larger doses in order to actually get the patient to sleep for 1-2 minutes”? If we are setting up for a procedural sedation anyway, let’s actually put them to sleep briefly and break the pain cycle. It seems somewhat counter-productive to say “we need to get them sleep” but have them awake enough to talk to us for the entire procedure.
3)Is this something we actually want to start promoting?
Regardless of the time commitment and feasibility of use, the most concerning element of using propofol for migraine may be the long term consequences. Will the possibility of a 30 minute to 1 hour procedural sedation lead to patient’s expecting this when they come in with a bad migraine? The recurrent migraine population also tends to overlap with the frequent flyers, and the repercussions of unmet expectations will lead to decreased satisfaction for both patients and staff. What happens when a few people in the ER group are providing this service while others are not? There is always practice variation, and we are unlikely to see widespread adoption of this therapy in the near future.
Back to the case.
I stopped at 30 minutes and 120 mg of propofol (about 1.5 mg/kg), and achieved a pain reduction from 10/10 to 5/10. I feel that the pain was steadily decreasing and by one hour (and 240 mg of propofol), she’d probably have been near 0/10. But that’s speculation. The patient was very appreciative, and felt well enough to be discharged, but I still question the role of this procedure.
The use of propofol for migraine headache has potential, but I question its practicality and whether it is something we want to advertise.
Overall, paraspinal and greater occipital nerve blocks may have a greater role as novel migraine therapies compared with propofol, primarily because of feasibility in practice. We’ll discuss these techniques further in part 2.
If you have experience with propofolizing migraines, please comment, I would love to hear your thoughts.
Thanks to Nadim Lalani (@ermentor) for peer-reviewing this post.