SBAR

 Acute Migraine Mystery in ED

A 32-year-old female presents to the emergency room with a complaint of a migraine. An avid cyclist, she describes falling from her mountain bike during a recreational bike-hike 2 weeks prior, followed by daily headaches that have been very painful (7 out of 10 on a 0–10 pain rating scale). The patient was not wearing a helmet at the time of the fall and states that she hit her head on a grassy embankment. She denies any loss of consciousness or lacerations; she also denies any altered state of alertness at the time of the accident or since the accident.  

A review of the patient’s electronic health record (EHR) by the ED nurse indicates that, in her visit 2 weeks earlier, she complained of head, neck, and hip pain at the time of the fall. X-rays performed were negative for any fractures. The patient was also assessed and found to be negative for a concussion. She admits having intermittent migraines for several years, which she attributed to allergies. The patient does not have health insurance.

At the time of the injury, the patient was prescribed acetaminophen to treat the headache and was discharged with a referral to a headache specialist. She denies seeing the specialist, stating that she could not afford the follow-up visit because she works part-time as a waitress. Since the initial ED visit, she reports frequent headaches occurring 4 to 5 times per week characterized by pressure behind her eyes and temple area. They are worse on days she works. She reports taking more acetaminophen than the recommended dosage because of the headache intensity. She states that she has been going into a dark closet at her workplace and closing her eyes, as this seems to alleviate the pain.

The patient also states that, at the end of the day, she often has neck pain and is fatigued. She has increased her caffeine intake to “get through the day” at work, consuming 4–6 cups of coffee daily.

After completing the initial assessment, the ED nurse notifies the ED-assigned nurse case manager, based on the patient’s non-compliance with the initial discharge orders, related to her financial limitations.

The nurse arrives at the patient’s bedside shortly after the ED physician completes the physical exam. Observes as the physician further assesses the patient’s history based on the following patient-interview areas:

· Medication review

· Re-evaluation of the head trauma and post-head-trauma period

· Headache triggers

· Sleep patterns and how she deals with fatigue

· Effectiveness of previous treatments for migraines

· Other contributing factors

After a complete interview with the patient and diagnostic workup, the ED physician concurs with the initial diagnosis at the time of the injury. He prescribes amitriptyline for the patient to alleviate the headaches and refers the patient to a specialist.