Case of the Month. 6.2013. | The KP EM Residency

Case of the Month. 6.2013.


A 45 yo female presents with the CC: MIGRAINE HEADACHE. Unilateral. Throbbing. Associated nausea and vomiting. Not the WHOL or thunderclap onset. Feels like her previous migraines. Tried Imitrex SQ without relief. Has been to the ED many times before with similar complaints. Patient is asking for her usual cocktail…
•Problem list: Migraines, chronic low back pain, major depression, hx of bariatric surgery, opioid dependence, generalized anxiety disorder, medication management – pain care plan
•Meds: Alprazolam, propranolol, fluoxetine, buproprion, gabapentin, sumatriptan
•Allergies: none
•Social history: Does not smoke, drink or use illicit substances
Physical Exam: Middle aged female in apparent distress found sitting in a dark room with dark sunglasses on. Otherwise, unremarkable and non-contributory.

  • Who has seen this patient before?
  • Who would administer narcotics?

ED Course:

•Patient given ketorolac 30 mg IV and metoclopramide 10 mg IV with no improvement.
•Patient then given bilateral cervical bupivacaine injections with complete resolution of headache within 10-15 minutes
•Sunglasses came off; patient now smiling and laughing with her husband

Cervical Injections for Migraine Headaches.

Retrospective review of 417 patients undergoing lower cervical intramuscular bupivacaine injections for headache in the ED
–217 (65.1%) with complete relief
–85 (20.4%) with partial relief
–57 (13.7%) with no relief
–4 (1%) with worsening of headache
–Relief typically rapid; many with resolution in 5 to 10 minutes
–No severe adverse outcomes reported


•Injection site is 2-3 cm lateral to C6-C7 area
•Inject 1.5 mL 0.5% bupivacaine 1 – 1.5 inches deep on each side
•Aspirate for blood prior to injecting
•Do not angle into the thorax

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Go ahead… give it a shot! (literally)

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