Abdominal migraine should be considered a possible source of incurable abdominal pain in adults when accompanied by a complete gastrointestinal workup with normal results. We recommend a trial of topiramate as prophylactic therapy if abdominal migraine is the likely source of the pain.

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Introduction: Limited guidance has been provided for opioid de-escalation when managing pain associated with vaso-occlusive crisis (VOC) in hospitalized patients with sickle cell disease (SCD). Therefore, a pain management protocol was developed for use in this population and piloted at a tertiary academic medical center.Objective: To assess implementation of a newly developed pain management protocol for use in hospitalized patients with a VOC.Methods: This was a retrospective, single-center, pre-post cohort study of SCD patients admitted with a VOC between June 1, 2018 to June 1, 2019 (pre-protocol) and December 31, 2019 to May 12, 2020 (post-protocol). The primary outcome was a reduction in intravenous (IV) short-acting opioid utilization as defined by the proportion of hospitalized days where the route of administration for short-acting opioids was oral rather than IV for ≥75% of doses given. Secondary outcomes included the proportion of hospitalized days where ≥50% and ≥25% of the short-acting opioid doses were administered by mouth. Opioid use (in morphine milligram equivalents [MME]) was also compared between groups.Results: A total of 96 admissions in the pre-protocol group and 29 admissions in the post-protocol group were included in the study. There was a statistically significant increase in the proportion of hospitalized days where ≥75% of the short-acting opioid doses were administered by mouth rather than IV in the post-protocol group compared with the pre-protocol group (0% vs 8.3%, P = .0114). Intravenous opioid use and total opioid use in the post-protocol group was lower compared with the pre-protocol group. Conclusion:Implementation of a pain management protocol for use in hospitalized SCD patients admitted with VOC was associated with an increase in the use of oral short-acting opioids and reduced overall opioid use.