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I think the last two EMN Articles may have a negative impact on practice.
This study concluded that intravenous Benadryl has no benefit for migraine, which contradicts the actual knowledge of many EPs. (EMN. 2023;45(4):1; https://tinyurl.com/2ywjex6y.) I have seen many headaches reversed using 12.5 mg diphenhydramine (with or without dexamethasone) and 10 mg metoclopramide (injected into a crystalline bolus). I believe that if all MEPs contributed their cases of successful treatment with similar cocktails, the numbers would be impressive.
My usual pre-treatment instructions are: “In half an hour, I’m going to wake you up and your headache will be much better or go away.” The 50 mg dose used in the study was too large and a major limitation of the trial. I only use this dose to treat allergic reactions.
I would also like to respond to the strong calls for an end to steroid use in URIs, as the evidence does not support this. (EMN. 2023;45(9):7; https://tinyurl.com/29x956c5.) I am also against inappropriate use of steroids, but I think severe congestion or upper respiratory tract inflammation is legitimate use.
This is very similar to how we know ibuprofen or acetaminophen won’t work for strep throat or a sprained ankle, but we use them to relieve pain. Patients who appear to be in agony from sinusitis experience acute relief within 15 minutes with an intramuscular injection of dexamethasone. Once you see this with your own eyes, you’ll understand. Oral doses may also be used by children or infants who suffer from suffocation at night due to nasal mucus.
If we were to discard common medications that don’t work, benzonatate, azithromycin, and fluticasone should be the first choices.
One of my responsibilities is to serve as the Medical Director of We Care Urgent Care. Two years ago, before taking on this role, I had no idea how useful steroids could be for relieving upper respiratory tract inflammation. I learned a lot by calling back every patient I saw, including how the medications I was trained to prescribe didn’t work for almost everyone.
Chuck Greene, DO
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