Migraine
Status Epilepticus in
Adults
Subarachnoid
Haemorrhage (SAH)
MIGRAINE
ASSESSMENT
Exclude other serious causes of headache
 SAH – Sudden, first or worst
 Meningitis – Fever, neck stiffness, rash
 Space occupying lesion – Neurological signs
TREATMENT
Non-Medicinal




Dark, quite room
IV fluids if dehydrated or giving IV medications
Oxygen
Reassurance and explanation
Oral Medication
Will often have been tried oral or SC medication at home but if not and the migraine is not yet severe
use these first.
First line

Aspirin 1200mg or Paracetamol 1500mg + Metoclopramide 10mg orally
Second line

Sumitriptan
100mg orally, 2hrly (repeat x 3); or 6mg SC (repeat at > 1 hour,
provided was initially effective)
Serotonin agonist with potent intracranial vasoconstrictor effects
77% effective at 1 hour, 83% at 2 hours, but 40% recurrence rate
Expensive
Side Effects:
Coronary artery constrictor
Hypertension
Dizzyness, fatigue, neck or chest pain, flushing
Contraindications: Ergotamine in preceding 24 hours
Ischaemic heart disease or risk factors for
Neurological signs
IV Medications
These are likely to be required for patients presenting to the ED
First Line
Metoclopramide
10mg aliquots, repeated at 30 minutes to 30mg IV.
Dopamine antagonist
80% effective
Controls nausea and vomiting
Side effects:
Dystonic reactions
Sedation
Second Line
1.
Chlorpromazine
12.5mg (slowly in 20ml N saline) aliquots to 75 mg IV
Dopamine antagonist
80% effective
Side effects:
Hypotension (Give IV fluids 500ml N Saline first)
Dystonic reactions
Sedation – more than above
Contraindications:
pregnancy, narrow angle glaucoma
Or
2. Prochlorperazine
10mg IV(slowly in 20ml N saline) repeated at 30 min to 40mg
Dopamine antagonist
75% effective at 1 hour
Also effective in tension headaches
Side effects:
Hypotension (Give IV fluids 500ml N Saline first)
Dystonic reactions
Sedation
Contraindications:
Pregnancy, narrow angle glaucoma
Or
3. Promethazine
H1 antagonist
Side effects:
Contraindications:
12.5 mg IV
Hypotension (Give IV fluids eg 500ml N Saline first)
Anti-cholinergic side effects
Dystonic reactions
Sedation
MAOI within previous 14 days
Third Line
1.
Lignocaine 1%
Contraindications:
1mg / Kg IV over 90 seconds
Impaired cardiac conduction
NEVER OPIATES
Opiates are less affective than all of the above. 50% effective compared to placebo of 45%. May lead
to addiction
DISCHARGE
When headache and any neurology have resolved.
Consider prophylaxis in liaison with GP

First line is to avoid precipitants eg chocolate, red wine, stress, oral contraceptive pill
Medication choice depends on comorbities

Pizotifin
0.5 –1mg nocte to 3mg
Food sensitive migraine
SEs – weight gain

Propranolol 40mg BD to 240mg daily
B Blocker

Amitryptyline 50mg nocte
TCA
May be added to above

NSAIDs

Cyproheptadine

Clonidine

Ca Channel Blocker – nifedipine, verapamil

Methysergide
Derivative of ergotamine
60% effective
Side Effects:
Retroperitoneal, pericardial and pleural fibrosis (decreased by drug holidays
of 4 weeks every 6 months)
For unresponsive severe migraine

MAOIs – phenelzine, moclobemide
INDICATION FOR REFERAL TO NEUROLOGY




Failure for headache or neurological signs to resolve
Diagnosis of migraine in doubt
Inadequate control with prophylaxis
Failure of therapy or need for IV lignocaine infusion
References:
Analgesic Guidelines. VMPF
Caesar R. Acute Headache Management: The Challenge of Deciphering Etiologies To Guide
Assessment and Treatment. Emergency Medicine Reports. 1995:16:117 - 128
STATUS EPILEPTICUS IN ADULTS
DEFINITION:
Two or more seizures without full recovery
or
Recurrent seizures > 30 min.
seizure duration < 1 hour: 2.7% mortality
> 1 hour: 32% mortality
(most deaths are late: 15 – 30 days)
CLASSIFICATION:
1. Generalized convulsive SE
2.
3.
Nonconvulsive (Complex partial; Absence
Simple partial SE
ETIOLOGY:
1.
2.
3.
Noncompliance / withdrawal / breakthrough
New onset seizure disorder
Secondary: Hypoxia
Metabolic: glucose, sodium, calcium
Toxicologic:
O/D: EtOH/TCA/stimulants/Tp
withdrawal: EtOH/BDZ/narcotic
Infectious
CVA, SOL, trauma
EVALUATION:
History:
? meningitis; drug ingestion; head injury;
past seizure / medical history; medicatons;
pregnancy.
Examination: vital signs, pupils/fundi, neck stiffness
trauma, aspiration, skin.
MANAGEMENT: Rationale for aggressive treatment:
-
the longer it persists, the harder it is to control
continuous excitatory activity = neuronal damage
systemic complications (eg. temp.) exacerbate damage
Goals:
-
Resuscitation;
terminate clinical and electrical seizure activity as rapidly as possible;
-
prevent recurrence;
identify precipitating factors;
correct metabolic imbalance; prevent systemic complications;
further evaluate and treat the cause of SE.
TIME
ACTION
0 – 5 minutes
ABC, MONITOR, IV, Blood Glucose / tests / drug levels
6 – 10
Treat hypoglycaemia (50 ml of 50 % glucose IV)
Thiamine 100 mg first if malnourished / alcoholic
IV MIDAZOLAM 0.1 –0.3 mg/kg
or DIAZEPAM 0.2 mg/kg (5 mg/min.)
REPEAT AS REQUIRED
10 – 30
Prevent recurrent seizures:
IV PHENYTOIN 20 mg/kg
@ rate < 50 mg/minute (monitor)
(watch for extravasation)
Treat cause.
If SE persists: DCCM REFERRAL
perform ETT intubation / ventilation
Start IV PHENOBARBITONE 20 mg/kg
@ rate < 100 mg/minute until seizures stop
> 60
If SE still persists other options: THIOPENTONE
PROPOFOL
LIGNOCAINE
Further reading:
Emergency Medicine Reports Vol. 18(14) July 7, 1997.
Epilepsia 39(suppl. 1):S28-35, 1998.
INVESTIGATION OF SUBARACHNOID
HAEMORRHAGE (SAH)
? SAH
CT
-ve
+ve or
GCS <15
Neurosurgical
Referral
+ve
Neurosurgical
Referral
GCS 15
LP at 12 hours
MRA or
Cerebral
Angiogram
-ve
Clinical Suspicion
High
low
Treat Headache
Discharge
 Up to 7% of patients with a SAH may have a normal initial CT.
 A delayed LP allows for red cells that have entered the CSF to lyse with the
production of bilirubin - xantho chromia. At Auckland this is determined by
visual inspection rather than spectrophotometry.
 Early LP does not distinguish a traumatic tap from a SAH.
Reference:
Foot C., Merfield E. Suspected Subarachnoid Haemorrhage with a Negative
CT Head Scan : What Next?. Emergency Medicine (2000) 12, 212-217.