From the Guidelines
For this patient with a headache rated 8/10 and fever of 100.9°F, I recommend administering ibuprofen 400 mg PO now for pain control, as it is a first-line treatment for migraine and has been shown to be effective in reducing headache severity 1. Given her low blood pressure (91/51,91/54), it is essential to monitor her vital signs closely, especially blood pressure, and ensure adequate hydration with IV fluids (consider normal saline at 100-125 mL/hr) to help with both the hypotension and headache. Since she already received Tylenol at 17:35 and it's not providing adequate relief, consider adding a mild opioid such as tramadol 50 mg PO or hydrocodone/acetaminophen 5/325 mg PO if the headache persists after 30-60 minutes. The patient should be reassessed in 1 hour to evaluate the effectiveness of pain management and monitor her fever and blood pressure. If headache persists or worsens despite these interventions, further workup may be needed to rule out secondary causes, particularly given the combination of headache, fever, and hypotension. Some key points to consider in the management of this patient's headache include:
- Avoiding NSAIDs like ketorolac that may further lower blood pressure 1
- Using acetaminophen-aspirin-caffeine combination as an alternative to ibuprofen if necessary 1
- Monitoring for potential adverse reactions to medications, such as gastrointestinal upset or drowsiness 1
From the Research
Patient's Condition
- The patient is complaining of a headache with a pain level of 8 out of 10.
- The patient had taken Tylenol at 17:35 due to a fever of 100.9 F.
- The patient's blood pressure is soft, with readings of 91/51 and 91/54.
- The patient had received toradol 15mg iv x1 in the ED at 10:39.
Treatment Options
- Ketorolac is a non-steroidal agent with potent analgesic and moderate anti-inflammatory activity, as shown in a study from 1990 2.
- A study from 1994 found that ketorolac has antipyretic effects, with a 30 mg intramuscular dose demonstrating approximately the same antipyretic activity as a 650 mg oral dose of acetaminophen 3.
- A randomized controlled trial from 2017 compared the analgesic efficacy of three doses of intravenous ketorolac (10,15, and 30 mg) in patients with acute pain, and found that all three doses provided similar pain reduction at 30 minutes 4.
- A study from 2005 compared the effects of morphine, ketorolac, and their combination for postoperative pain, and found that opioids are more efficacious analgesics than NSAIDs, but that adding NSAIDs to opioid treatment reduces morphine requirements and opioid-related side effects 5.
Potential Next Steps
- Consider administering additional pain medication, such as morphine, if the patient's pain level remains high.
- Monitor the patient's blood pressure and fever closely, and adjust treatment as needed.
- Consider alternative treatments, such as acetaminophen, if the patient's pain level is not adequately managed with ketorolac.