A Third Way: The Headache “Rescue Room”
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You: I have a terrible migraine headache, and it just will not stop! I’ve tried every medicine the doctor prescribed, more Excedrin than I care to remember, hot compresses, cold compresses, resting in a dark, quiet room and just giving up and going to sleep. But it’s still there when I wake up! This has been going on for 3 days now, and I don’t know what to do. My last trip to the emergency room for a bad migraine was a disaster–after waiting for 4 hours under the neon lights and with all the noise and chaos, I just gave up and went back home without being seen. I am sick of feeling so sick, but what can I do?
[Pause] I know. I’ll call my doctor
You call and leave a message. Hours pass. Evening comes. The phone rings…
Doctor: “I have a message here that you called. What can I do for you?”
You: “I have a headache.”
Doctor: [silence]
You [breaking silence]: “It’s really a bad one. I’ve been too sick to go to work for the past 3 days.”
Doctor: “Have you taken your medications for acute headache and nausea?”
You: “Yes. They’re not helping.”
Doctor: “Well, I’m sorry, but there’s not much I can do over the phone. Maybe it’s time to go to the ER?”
You: “Okay” [thinking: Thanks for nothing.]
Call ends.
Not a very satisfying or productive interaction. And I know, believe me, because I participated on the doctor end in an awful lot of these interactions over the years. So many, in fact, that I eventually decided to do something about it.
With the help of my clinic nurse, we established what we decided to name “the headache rescue room.” Put simply, we restructured one of the exam rooms in clinic to make it as comfortable as possible for a patient with acute severe migraine headache and associated symptoms. We obtained an arsenal of intramuscularly and intravenously administered medications for acute headache, medications for nausea, a few medications to treat elevated blood pressure and numerous bags of normal saline for intravenous hydration.
We developed a management strategy that ran the gamut from the initial evaluation to an evidence-based, stepwise treatment algorithm to an exit evaluation that would include confirmation patients had appropriate transportation for the trip back home. To evaluate prospectively the effectiveness of our new “rescue room” we developed a research protocol that included assessments of clinical effectiveness, safety, cost and patient satisfaction. In accordance with the protocol, all patients were contacted 24 hours after treatment for a follow-up assessment.
When we were all set, we advised our clinic’s established migraine patients that if they experienced an episode of severe migraine that resisted self-administered therapy, they could call a dedicated phone number and request to be evaluated and treated in the “rescue room”. The rescue room was available to them all day on weekdays.
Each of the initial 100 consecutive patients treated in the rescue room provided informed consent to participate in our study. To summarize, virtually all of the 100 patients reported significant headache relief or freedom from headache at the time of exit from the clinic. On a five-point scale, 95% reported their degree of satisfaction with the rescue room to be “good” (32%) or “excellent” (63%). The average total cost for a rescue room visit was just over $160. Many of the patient’s involved in our study previously had sought care for acute migraine headache at an emergency room, and the average cost for an ER visit was approximately $1700…10 times that of the cost associated with use of the rescue room.
At my present institution we have a small suite devoted exclusively to rescue room patients, 3 nurse practitioners who alternate in managing the rescue room, 2 faculty physicians who supervise the nurse practitioners and a registered nurse who assists with hands-on patient care. When the COVID pandemic shut down our rescue room for months, it provided both us, the providers, and our migraine population an all too clear view of how nicely this service had met the needs of patients who now were left once again to choose between the potential discomfort and inconvenience of an ER versus suffering in silence at home.
Thankfully, the doors have reopened, and our patients once again have the security of knowing that another and more attractive option exists for those times “when the headache just won’t quit”.
