Does Ketorolac Improve Your Migraine Cocktail?
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This systematic review found IM or IV ketorolac had similar efficacy in treating acute migraine headache as phenothiazines and metoclopramide but was unable to draw significant conclusions about ketorolac in comparison to other therapies or as part of a multi-drug cocktail due to paucity of evidence.
Source
Efficacy of ketorolac in the treatment of acute migraine attack: A systematic review and meta-analysis. Acad Emerg Med. 2022 Sep;29(9):1118-1131. doi: 10.1111/acem.14457. Epub 2022 Mar 10.
Accuracy of Neuroimaging for Dizziness – It’s Not Pretty
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We cannot rely on neuroimaging (CT, CTA, MRI or MRA) alone to effectively rule out stroke in patients presenting to the ED with acute dizziness or vertigo.
Should Benadryl Be in Your Migraine Cocktail?
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There is still no strong evidence to suggest that an anticholinergic agent should be administered prophylactically to prevent extrapyramidal symptoms when treating migraine.
Source
Adjuvant anticholinergic therapy for the prevention of akathisia in patients with primary headache in the emergency department: a systematic review. Acad Emerg Med. 2022 Aug 13. doi: 10.1111/acem.14581. Online ahead of print.
NOR-TEST 2 – What’s the Right Dose of Tenecteplase for Stroke?
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Tenecteplase, at a dose of 0.4 mg/kg, is not safe for patients with moderate to severe ischemic stroke.
Source
Tenecteplase versus alteplase for the management of acute ischaemic stroke in Norway (NOR-TEST 2, part A): a phase 3, randomised, open-label, blinded endpoint, non-inferiority trial. Lancet Neurol. 2022 Jun;21(6):511-519. doi: 10.1016/S1474-4422(22)00124-7. Epub 2022 May 4.
Mental Gymnastics – Does Yoga Help Migraines?
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This meta-analysis supports the recommendation of yoga as a treatment for migraine. How this generalizes to the emergency department is unknown.
Source
Effectiveness of yoga therapy for migraine treatment: A meta-analysis of randomized controlled studies. Am J Emerg Med. 2022 May 2;58:95-99. doi: 10.1016/j.ajem.2022.04.050. Epub ahead of print.
Spontaneous Intracranial Hypotension – Spoon-Feed Version
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This is an update on the presentation, diagnosis, and management of spontaneous intracranial hypotension.
Source
Spontaneous Intracranial Hypotension. N Engl J Med. 2021 Dec 2;385(23):2173-2178. doi: 10.1056/NEJMra2101561
How to Use Nerve Blocks for Acute Headache
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Peripheral nerve blocks may help achieve symptomatic improvement in our primary headache patients, but we are still far off with research supporting it as a first line intervention.
Source
Effectiveness of Peripheral Nerve Blocks for the Treatment of Primary Headache Disorders: A Systematic Review and Meta-Analysis. Ann Emerg Med. 2022 Mar;79(3):251-261. doi: 10.1016/j.annemergmed.2021.08.007. Epub 2021 Oct 28.
Does NOAC Use Preclude tPA for Acute Stroke?
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There was no significant difference in intracranial hemorrhage, serious systemic hemorrhage, or inpatient mortality for patients who used non-vitamin K oral anticoagulants in the seven days prior to receiving alteplase for acute ischemic stroke.
Source
Association of Recent Use of Non-Vitamin K Antagonist Oral Anticoagulants With Intracranial Hemorrhage Among Patients With Acute Ischemic Stroke Treated With Alteplase. JAMA. 2022 Feb 22;327(8):760-771. doi: 10.1001/jama.2022.0948.
Early Endovascular Therapy for Basilar Artery Occlusion
Time from symptom onset of a basilar artery occlusion (BAO) to endovascular therapy (EVT) of less than 6 hours compared to greater than 6 hours (up to 24 hours) was associated with lower odds of in-hospital mortality, disability, symptomatic intracranial hemorrhage, and higher odds of ambulation at discharge, discharge home and reperfusion.
Source
Association Between Endovascular Therapy Time to Treatment and Outcomes in Patients with Basilar Artery Occlusion. Circulation. 2022 Jan 20. doi: 10.1161/CIRCULATIONAHA.121.056554. Online ahead of print.