Briefly describe a specific question, or set of related questions, about a health care test or treatment that this program should consider.

Migraine patients in the ER receive various IV medications from different ER doctors within the physician group. As I have watched particular drug combinations given to my patients and to my daughter in the ER, I have witnessed total relief of the migraine with the following 3 IV meds: IV benadryl 25 mg followed by IV toradol 15mg followed by IV reglan 10mg; in addition, 1 liter .9NS infusing wide open x 1 liter total amt. Narcotics IV require multiple doses and usually do not totall relieve the migraine. Also, patients can not drive home or function at work etc for 4 hours after dose given. An older drug, DHE, an ergot, often causes nausea and additional anti nausea meds are then required. DHE is ineffective usually. However, I had a migraine pt with cerebri (excessive build up of cerebral spinal fluid) who was resistant to many combinations of IV meds and got total relief from DHE finally. She did not have a spinal tap to remove CSF, I would like to see research based evidence supporting

combination of 1 L .9NS and IV benadryl 25 mg followed by IV toradol 15mg-30mg followed by IV reglan 10mg (IV push)

Does your question include a comparison of different health care approaches? (If no, your topic will still be considered.)

yes

If yes, explain the specific technologies, devices, drugs, or interventions you would like to see compared:

IV benadryl, toradol and reglan compared to IV morphine, dilaudid,fentanyl,zofran,phenergan.

What patients or group(s) of patients does your question apply to? (Please include specific details such as age range, gender, coexisting diagnoses, and indications for therapy.)

Migraine patients resistant to their home meds presenting in the ER. I believe we need to have available in doctor offices and pharmacy clinics IV access, IV fluids (.9NS) and IV meds (limited) for relief of migraines and viral illness causing nausea and vomiting. There will be a huge reduction in ER visits as well as extrememly high costs (ie approx $3000.00 for 1.5 hours in ER for Migraine treatment with IV benadryl,toradol,reglan and a liter of .9 NS).

Are there subgroups of patients that your question might apply to? (For example, an ethnic group, stage or severity of a disease.)

Mostly females, late teens to 40's

Describe the health-related benefits you are interested in. (For example, improvements in patient symptoms or problems from treatment or diagnosis.)

Symptoms are completely relieved with one round of the three IV meds with one liter of .9normal saline.

I would like to see the categories of these medications in oral form so that patients can get relief at home, if the oral route would even work.

Describe any health-related risks, side effects, or harms that you are concerned about.

Some have adverse reaction to reglan (extrapyramidal effects) displayed by acute anxiety and claustrphobia.

However, giving benadryl prior to reglan prevents this negative reaction. Benadryl also promotes sleep of which also plays an important role in relieving the migraine.

Appropriateness for EHC Program

Does your question include a health care drug, intervention, device, or technology available (or likely to be available) in the U.S.?

yes

Which priority area(s) and population(s) does this topic apply to? (check all that apply)

EHC Priority Conditions (updated in 2008)

AHRQ Priority Populations

• Women

Federal Health Care Program

None

Importance

Describe why this topic is important.

It works! Migraines are relieved ! It is cost effective (verses trial and error ornot giving pt this combination first) ER's are very expensive. The cost for this treatment in the ER is absolutely rediculous.

There needs to be more options with legal protection to treat migraine sufferers with IV fluids and IV meds in settings other than the ER . As well, if in theER, there needs tobe a set universal cost equal to or less than $500.00 (verses the $3000.00 received from insurance companies or patients out of pocked, or from hospital charity fund). I am a RN BSN and witness to caring for Migraine treatment. My daughter gets migraines and has had to go to the ER twice in the last 3 years. She received the trio combination with 1 l NS at hospital ER "A" and woke in one hour totally pain free.

She went to another ER, ER "B" 3 yrs later and received DHE which caused worse nausea and induced vomiting and did not relieve the pain. In addition, they gave her zofran. Now, receiving 2 additional meds and costs unnescessarily. (I had requested the IV trio and denied by the DR.) Next, this Dr gave the IV trio I originally requested and she became totally pain free. It isimportant that doctors give what worked before instead of what they want or instead of reinventing the wheel. Doctors need to always partner with the patients in their treatment and listen to the patients. (Often, doctors do, but not all and not enough). Consumers are paying out of pocket more and more for their health care. Treatment must be what is known to have very high effective results and the least amount of tests.

What specifically motivated you to ask this question? (For example, you are developing a clinical guideline, working with a policy with large uncertainty about the appropriate approach, costly intervention, new research you have read, items in the media you may have seen, a clinical practice dilemma you know of, etc.)

Experience with ERs.

Does your question represent uncertainty for clinicians and/or policy-makers? (For example, variations in clinical care, controversy in what constitutes appropriate clinical care, or a policy decision.)

no

If yes, please explain:

Like universal treatment for cardiac chest pain, migraines and other problems need to follow the same processes.

Potential Impact

How will an answer to your research question be used or help inform decisions for you or your group?

We are starting to see more ER doctors prescribe the IV trio meds with great success of relief of migraines initially.

Describe the timeframe in which an answer to your question is needed.

Describe any health disparities, inequities, or impact on vulnerable populations your question applies to.

This treatment needs to be done in physician offices and clinics. Many MD's fear it sets them up for legal issues they say. It is very cost effective to be done in offices and clinics, especially for the underserved populations.

Many MD's fear it sets them up for legal issues they say.

CT's of the brain are not done routinely on patients who present with migraine symptoms (recurring)anymore (for years now).

Nominator Information

Other Information About You: (optional)

Please choose a description that best describes your role or perspective: (you may select more than one category if appropriate)

We are starting to see more ER doctors prescribe the IV trio meds with great success of relief of migraines initially.

Are you making a suggestion as an individual or on behalf of an organization?

Individual

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