Occasionally patients with difficult to treat migraines must be hospitalized to find effective treatment. If you are a patient who has or may be hospitalized, if may be useful for you to consider how your doctor thinks about hospitalization.
Why patients are hospitalized
The reasons for hospitalization are many but the most common reason is a severe, intractable migraine, persisting for at least a few days, that has been unresponsive to outpatient therapies. In our office, outpatient therapy may include outpatient intravenous medications over the course of 2 or 3 days.
Another reason for hospitalization is the develoment of severe nausea and vomiting with associated dehydration. This is treated typically with IV antinauseants as well as IV normal saline infusion.
Patients may also be hospitalized both to treat and to further work up their headaches. For example, a patient with known migraines whose headache pattern is changing or with new symptoms, might be in need of brain imaging or other evaluations to see if a new cause of headaches has developed.
The Standard Approach
Your admitting doctor usually has in mind a 1-3 day stay in the hospital, treating you with medications that have a good record of ending severe unrelenting migraine (status migrainosus). One of the most common medications used for this purpose is dihydroergotamine (DHE), which is administered intravenously every 8 hours. The medication acts as a vasoconstrictor (constricting blood vessels in the brain) but also affects the brainstem receptors (5HT1) that are involved with migraine. Because this medication commonly causes nausea, anti-nausea medications such as phenergan or Reglan are also administered.
Other IV therapies may also be added or substituted. These are chosen based on what medications a patient has responded to in the past and potential other benefits or side effects. Examples include IV Benadryl, magnesium sulfate, Depacon, and droperidol. The anti-nauseants Reglan or phenergan may be included too since they have both anti-nausea and anti-migraine effects.
If DHE is not effective, it may still be useful to explore the use of triptan medications (another class of vasoactive medications) especially subcutaneous injections of sumatriptan.
IV steroids (Solumedrol, Decadron) are powerful anti-inflammatory medications that also may be added to reduce headaches. These probably work by reducing the inflammation in the brain that is known to occur in migraine.
Narcotic medications are often also included in a patient's treatment. These include IV Dilaudid, IV Demerol, or IV morphine. Physicians are often somewhat reluctant to give patients large doses of IV narcotics, given the potential for abuse, dependence, and even respiratory depression. In addition, once a patient is placed on these medications, if in fact they do not improve, it can be very difficult to reduce the doses.
Other types of treatment
It is important to pay attention to other factors that affect headaches. Patients usually appreciate private rooms so as to avoid noise. Insomnia should be treated as well as depression or anxiety. Some patients have irritation of the nerves in the back of the head (occipital neuralgia) and so may undergo an occipital nerve block while they are hospitalized. If a patient is not on a migraine preventative medication, maybe they should be - so this needs to be addressed. If they are on a preventative, perhaps the dose needs to be increased or an alternative can be sought.
Nursing Issues
While it should be that your doctors writes orders and your nurses carry them out, it is often not that simple. Each shift in the hospital is different, wtih night shift nurses usually having more patients to take care of and therefore being less responsive to your requests. The time between requesting a medication and getting it may be greater than an hour. In addition, some nurses begin to resent migraine patients. They appear often to be too demanding, requesting not only pain medications but that the shades be drawn or that the noise be limited. Nurses may suspect that a patient is simply 'hooked' on narcotics, and so do everything possible to avoid giving them to the patient. This can have the effect of greatly increasing a patients pain due to frustration.
Discharge
Getting out of the hospital can be more difficult than getting in. A patient with infrequent headaches whose migraine responded well to hospitalization may be able to be discharged on an oral preventative and can keep using their usual home medications (oral triptan, Fioricet, Fiorinal, ibuprofen, etc.). On the other hand, some patients don't respond to multiple medications given, except to narcotics. They may be getting temporary relief with the narcotics, but may have no overall dimunition in the headache intensity from one day to the next. After being hospitalized for a week, it is often unclear how to proceed, the situation becoming frustrating for both the patient and physician. In addition, insurances may threaten not to continue paying for the hospitalization. In these cases, there is no easy answer. Some patient leave the hospital still experiencing significant headaches, using intramuscularly injected narcotics, or self-injecting DHE (or other medications) via a semi-permanent IV. The hope in these cases is that with use of preventatives and a slow taper, the patient can get off of injectible medications.
Will health insurance pay for the hospitalization?
This is not certain. In the best circumstance, the admission is pre-authorized through a patient's health insurance, and therefore, the hospitalization will generally be paid for. If a patient is admitted without pre-authorization, such as directly from an emergency room, then payment varies. Each health insurer has its own criteria for admission status. If they feel you do not qualify, they can deny the entire hospitalization, potentially leaving you with a very large bill. Usually, though the issue is the intensity of hospitalization. Patients may only qualify for 'observation' status - which means that the insurance company won't pay the entire bill but will pay a portion of it.
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