🩺 THIS WEEK IN EM
IV Saline for Acute Migraine: The Ritual Is Stronger Than the Evidence
The migraine fluid bolus has become one of those ED habits that feels self-justifying. The patient looks miserable, they are often nauseated, they have probably not been drinking much, and hanging a liter seems both kind and productive. The problem is that we often treat the bag as if it is part of the analgesic regimen even when dehydration is not actually the issue.
Turan and colleagues tested that reflex in a double-blind randomized trial at a single-center tertiary academic ED. Adults with acute migraine received standard NSAID-based treatment with 75 mg intramuscular diclofenac. The intervention group got 1,000 mL of intravenous normal saline over an hour; the control group got 10 mL over the same period. Importantly, patients with dehydration, recent IV fluid use, or fluid contraindications were excluded, which makes this a study of routine add-on hydration rather than resuscitation of someone who is actually volume depleted.
The primary result was underwhelming. Median pain reduction on a 100-mm visual analog scale at 2 hours was 62 mm with the liter versus 48 mm in the control group, for an estimated between-group difference of 10 mm with a 95% confidence interval from -2 to 20. In other words, there was no clear improvement in the main outcome. Secondary findings looked more flattering for fluids: rescue medication use was lower in the liter group, and ED length of stay was modestly shorter. But the authors are appropriately cautious here, because those secondary outcomes are easier to influence when bedside staff are not fully blinded to who is dragging around a real fluid bag.
That is the practical takeaway. This trial does not say fluids are useless in migraine. It says fluids should stop being automatic in migraine patients who are not clinically dehydrated. If the patient has been vomiting for hours, looks dry, or needs IV access anyway for other reasons, saline is easy to defend. If they are hemodynamically fine and you are giving it because “we always do,” the evidence gets thinner fast.
There is also a workflow lesson hiding in this paper. IV fluids consume line time, pump time, nursing attention, and often patient time tethered to a pole. If the actual analgesic effect is uncertain in euvolemic patients, then the bag should be treated as a selective intervention, not default décor.
Bottom line: In adults with acute migraine who were not dehydrated, adding 1 liter of normal saline to NSAID-based treatment did not clearly improve pain at 2 hours. Give fluids when the patient looks volume depleted, not because migraine care in the ED has drifted into hydration ritual.
Turan Y, Akoglu H, Unal E, et al. Efficacy of Adding Intravenous Saline Solution to Nonsteroidal Anti-Inflammatory Drug-Based Treatment of Acute Migraine in the Emergency Department. Ann Emerg Med. 2026.
Sphenopalatine Ganglion Block for ED Headache: A Bigger Dose Does Not Rescue the Idea
Sphenopalatine ganglion block has obvious emergency medicine appeal. It is non-opioid, relatively quick, and feels procedurally elegant in the way many headache interventions do. That has led to the usual escalation instinct: if some local anesthetic is good, maybe more is better. This trial suggests that is not the answer.
McCarthy and colleagues ran a randomized 4-arm dose-finding study in two EDs, enrolling patients with moderate or severe primary or secondary headache. Patients were assigned to unilateral or bilateral transnasal SPG block using 0.5% bupivacaine and then to either a low dose (1 mL) or high dose (3 mL), creating four total-dose strategies ranging from 1 mL unilateral to 6 mL bilateral. The primary outcome was not short-lived improvement at 15 minutes, but sustained headache relief: mild or no headache within 2 hours and still mild or none for 48 hours without rescue medication.
That is a fair outcome, and the results were messy in exactly the way dose-escalation enthusiasm hates. Sustained relief rates were 31% for 3 mL bilateral, 34% for 3 mL unilateral, 35% for 1 mL bilateral, and 19% for 1 mL unilateral. Compared with the lowest-dose unilateral approach, neither high-dose strategy produced a clear improvement, and there was no significant difference in whether patients said they would want the treatment again. Minor procedure-related adverse events were uncommon across all groups.
Two details matter here. First, this was not a sham-controlled efficacy trial, so it does not let us say SPG block definitively works or does not work overall. It answers a narrower question: once you are doing the block, more bupivacaine does not buy you more durable relief. Second, 65% of screened patients refused participation because they preferred a route other than nasal. That is not a side note. It is a real-world usability signal.
So where does that leave the procedure? Probably where a lot of ED procedures end up after the adrenaline wears off: still reasonable in selected patients, not supported as a dose-escalation win, and less universally attractive than enthusiasts assume. If you already use SPG block and the patient is open to it, fine. But this paper does not justify a “just push more volume” approach, and it definitely does not prove the block should replace conventional headache therapy.
Bottom line: In ED patients undergoing sphenopalatine ganglion block for headache, larger volumes of bupivacaine did not produce more sustained relief than smaller volumes. If you use SPG block, more anesthetic is not the trick that makes it work.
McCarthy D, Borrayes L, Hopper E, et al. A Randomized, Dose-Finding Study of Sphenopalatine Ganglion Block With Bupivacaine for Emergency Department Patients With Headache. Ann Emerg Med. 2026.
Difficult IV Access: Venous Transillumination Looks More Useful Than Most Gadgets
Every ED has a population of patients who turn a routine IV into a time sink: chronic illness, edema, obesity, prior chemotherapy, terrible lighting, vasoconstriction, exhausted peripheral veins. Ultrasound is the obvious higher-skill answer, but not every stick needs a full ultrasound escalation. The question is whether a simpler device can meaningfully improve first-pass success before the room turns into a vascular access committee.
Simon and colleagues studied that in a prospective multicenter cluster-randomized trial across three French hospitals. Adults qualified if they met at least one predefined difficult-access criterion, including extreme BMI, hypotension, history of drug abuse, restricted puncture sites, dehydration, generalized edema, hypothermia, or limited venous capital from prior treatment. Weeks were assigned to either venous transillumination or usual care. The primary outcome was first-attempt success.
This is one of those papers where the headline number is hard to ignore. First-pass success was 70% in the transillumination group versus 41% with the usual method. The median number of attempts before success was also lower. What did not change was patient pain or nurse stress, which is useful because it argues the main benefit here was procedural efficiency rather than a softer bedside experience.
The caveats matter. This was an open-label trial using usual care as the comparator, not ultrasound-guided cannulation. The study was done in French EDs, so local staffing patterns and escalation thresholds may not map perfectly onto your shop. And the paper does not argue that transillumination replaces ultrasound for the truly awful stick. What it does suggest is that for the hard-but-not-impossible IV, a low-complexity device may rescue a meaningful chunk of first-pass failures before you escalate to more resource-intensive options.
That is probably the right lane for this tool in the United States too, assuming your department can actually stock one. Not as a replacement for ultrasound, not as a substitute for calling your best vascular-access person, but as an early adjunct for patients you can identify as difficult access before the third failed attempt.
Bottom line: In adults with difficult vascular access, venous transillumination markedly improved first-attempt IV success compared with usual practice. It looks most useful as an early adjunct for the hard stick, not as a replacement for ultrasound when access is truly difficult.
Simon M, Staszewski C, Luette S, et al. Effectiveness of venous transillumination on peripheral venous line placement in emergency departments patients with difficult vascular access: a multicentre cluster-randomised trial. Eur J Emerg Med. 2026;33(1):38-44.
🔭 Next Week
• Acute VTE treatment at discharge: COBRRA asks whether apixaban is now the safer default over rivaroxaban after the first head-to-head randomized trial
• Suspected PE in active cancer: can the YEARS algorithm safely avoid reflex CTPA?
• Preschool wheeze in the ED: does azithromycin help at all, or is this just antibiotic habit?
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— The Hallway Consult team