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Oral Narcotic Protocol to Reduce Narcotic Injections in Refractory Migraine Patients


Dr. Randal L. Von Seggern, Adelman Headache Center, 510 North Elam Avenue, Suite 302, Greensboro, NC 27403.


Refractory headache patients who require narcotic injections for acute attacks frequently utilize health care facilities. The experience is often unpleasant and costly to the patient and health care system.

We have developed an oral narcotic protocol for home administration. The patient starts with an antiemetic suppository, followed in 30 minutes by oral metoclopramide. After controlling nausea and vomiting, the patient administers a high dose of oral narcotic plus a hypnotic. The dosing of the narcotic analgesics incorporates seldom-used, but well-published pharmacokinetics. This protocol allows the patient to successfully treat a severe headache without using a health care facility.

Eleven patients in our practice were prescribed the oral narcotic protocol. Their need for narcotic injections at our office or emergency department was monitored for up to 1 year before and after the start of the protocol. Combined office visits were reduced from 81 to 53 (34.6%) and emergency department visits from 47 to 26 (44.7%). An annual cost savings of $1960 for office visits and $3024 for emergency department visits was realized. This was offset by an oral narcotic protocol medication cost of only $392. This treatment method has been well accepted by patients and has proven to be a safe and cost-effective approach to treating refractory migraine patients.