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Rattanawong W, Rapoport A, Srikiatkhachorn A. Medication "underuse" headache. Cephalalgia 2024; 44:3331024241245658. [PMID: 38613233 DOI: 10.1177/03331024241245658] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/14/2024]
Abstract
BACKGROUND Many risk factors have been associated with migraine progression, including insufficient and ineffective utilization of migraine medications; however, they have been inadequately explored. This has resulted in suboptimal usage of medications without effective altering of prescribing recommendations for patients, posing a risk for migraine chronification. METHODS Our aim is to conduct a comprehensive review of the available evidence regarding the underuse of migraine medications, both acute and preventive. The term "underuse" includes, but is not limited to: (1) ineffective use of appropriate and inappropriate medication; (2) underutilization; (3) inappropriate timing of usage; and (4) patient dissatisfaction with medication. RESULTS The underuse of both acute and preventive medications has been shown to contribute to the progression of migraine. In terms of acute medication, chronification occurs as a result of insufficient drug use, including failure of the prescriber to select the appropriate type based on pain intensity and disability, patients taking medication too late (more than 60 minutes after the onset or after central sensitization has occurred as evidenced by allodynia), and discontinuation because of lack of effect or intolerable side effects. The underlying cause of inadequate effectiveness of acute medication lies in its inability to halt the propagation of peripheral activation to central sensitization in a timely manner. For oral and injectable preventive migraine medications, insufficient efficacy and intolerable side effects have led to poor adherence and discontinuation with subsequent progression of migraine. The underlying pathophysiology here is rooted in the repetitive stimulation of afferent sensory pain fibers, followed by ascending brainstem pain pathways plus dysfunction of the endogenous descending brainstem pain inhibitory pathway. Although anti-calcitonin gene-related peptide (CGRP) medications partially address pain caused by the above factors, including decreased efficacy and tolerability from conventional therapy, some patients do not respond well to this treatment. Research suggests that initiating preventive anti-CGRP treatment at an early stage (during low frequency episodic migraine attacks) is more beneficial than commencing it during high frequency episodic attacks or when chronic migraine has begun. CONCLUSIONS The term "medication underuse" is underrecognized, but it holds significant importance. Optimal usage of acute care and preventive migraine medications could potentially prevent migraine chronification and improve the treatment of migraine attacks.
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Affiliation(s)
- Wanakorn Rattanawong
- Faculty of Medicine, King Mongkut's Institute of Technology Ladkrabang, Bangkok, Thailand
| | - Alan Rapoport
- Department of Neurology, The David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Anan Srikiatkhachorn
- Faculty of Medicine, King Mongkut's Institute of Technology Ladkrabang, Bangkok, Thailand
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Rhudy C, Schadler A, Huffmyer M, Porter L. Rural disparities in emergency department utilization for migraine care. Headache 2024; 64:37-47. [PMID: 38087895 DOI: 10.1111/head.14659] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Revised: 09/21/2023] [Accepted: 10/09/2023] [Indexed: 01/23/2024]
Abstract
OBJECTIVE To evaluate differences in emergency department (ED) utilization and quality of care for migraine in patients with rural and nonrural residences. BACKGROUND Migraine is a significant problem in the United States with direct health-care utilization cost amounting to US $4.2 billion annually. A considerable portion of this cost is attributed to more than 4 million annual ED visits for migraine and headache. Previous research has documented health disparities among rural populations in other disease states, which can be influenced by factors such as socioeconomic status and health-care access. Given these associations, it was hypothesized that patients with rural residence in a national sample would have increased ED utilization for migraine compared to patients with nonrural residence. METHODS This was a cross-sectional epidemiologic study to evaluate rural disparities in ED utilization and quality of care for migraine in the United States in 2019. ED encounter data were collected from the Healthcare Cost and Utilization Project (HCUP) Nationwide Emergency Department Sample (NEDS) and Kentucky State Emergency Department Database (KY-SEDD). The primary outcome was crude and age-adjusted rates of ED encounters for migraine per 10,000 population. ED encounters were included if they had a primary International Classification of Diseases, Tenth Revision, Clinical Modification diagnosis code of G43.xx. ED encounters lacking sufficient data to classify into a geographic group were excluded. Secondary outcomes examined differences in quality of care, including mean ED charges and the proportion of encounters with medication administration, imaging, and nerve block service codes between groups. RESULTS One hundred eighty-three thousand two hundred eleven national ED discharges were classified as rural patient encounters and 627,176 were classified as nonrural. The rural group had significantly higher crude and age-adjusted rates of ED utilization for migraine (crude: rural 39.8, 95% confidence interval [CI] 36.9-42.7; nonrural 22.2, 95% CI 21-23.5 and age-adjusted: rural 41.8, 95% CI 38.8-44.8; nonrural 23.4, 95% CI 22.1-24.7). Opioid utilization was higher in rural encounters (rural n = 26,764, 14.6%; nonrural n = 50,367, 8%; p < 0.001). A Kentucky sub-analysis found 5210 ED discharges were classified as Appalachian and 12,551 as non-Appalachian. The Appalachian group had significantly higher ED utilization rates for migraine compared to the non-Appalachian and national rural groups (crude: Appalachian 44.9, 95% CI 43.7-46.2; age-adjusted: Appalachian 47.4, 95% CI 46.1-48.8). The Kentucky Appalachian group also demonstrated significantly higher opioid analgesia use compared to the national rural group (Appalachian n = 1031, 19.8%; p < 0.001). CONCLUSION This study suggests rural populations, particularly in Appalachia, may experience significantly higher ED utilization for migraine compared to nonrural patients. Moreover, rural populations were more likely to receive suboptimal migraine management with opioid analgesia. Multimodal health-care interventions should be developed to improve access to outpatient migraine care and further investigate potential risk factors in the rural population. With high ED utilization, the Appalachian population may benefit most from such an intervention.
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Affiliation(s)
- Christian Rhudy
- Specialty Pharmacy and Infusion Services, University of Kentucky Healthcare, Lexington, Kentucky, USA
| | - Aric Schadler
- Department of Pharmacy, Kentucky Children's Hospital, University of Kentucky HealthCare, Lexington, Kentucky, USA
| | - Mark Huffmyer
- Specialty Pharmacy and Infusion Services, University of Kentucky Healthcare, Lexington, Kentucky, USA
| | - Lindsey Porter
- Specialty Pharmacy and Infusion Services, University of Kentucky Healthcare, Lexington, Kentucky, USA
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Alzahrani F, Alahmadi YM, Thagfan SSA, Alolayan S, Elbadawy HM. Migraine Management in Community Pharmacies: Knowledge, Attitude and Practice Patterns of Pharmacists in Saudi Arabia. PHARMACY 2023; 11:155. [PMID: 37888500 PMCID: PMC10610077 DOI: 10.3390/pharmacy11050155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Revised: 08/29/2023] [Accepted: 09/21/2023] [Indexed: 10/28/2023] Open
Abstract
In Saudi Arabia, community pharmacies offer healthcare services for different conditions. However, clarity of the competence of pharmacists in managing migraines is lacking. This study aimed to explore the current knowledge, attitude, and practice patterns of community pharmacists concerning migraine management in the northwestern part of Saudi Arabia. A cross-sectional study was carried out between June and September 2022 among 215 Saudi community pharmacists. Data analysis was performed by descriptive and inferential statistics using SPSS version 27. Most community pharmacists (87.9%) feel that migraine management is essential to their practice, and 83.3% suggest between one and five over-the-counter (OTC) migraine products daily. Among the study pharmacists, 83.7% feel migraine patients should try OTC before prescription medications. Only 9.3% of the community pharmacists do not believe that migraine is a neurological disorder. The medications most prescribed for migraine were triptans, representing 52.1% of prescriptions. There were significant differences between the gender of the pharmacists and their knowledge, attitude, and practice overall score (p-value = 0.04). Male pharmacists exhibited higher knowledge, attitude, and practice scores than female pharmacists. Although many community pharmacists acknowledge their expertise and involvement in managing migraines, there is a requirement for further education and training to enhance their capacity to offer complete care to migraine patients. Pharmacists should also consider non-pharmacological interventions and complementary therapies when treating migraine symptoms.
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Affiliation(s)
- Fahad Alzahrani
- Department of Clinical and Hospital Pharmacy, College of Pharmacy, Taibah University, Madinah 42353, Saudi Arabia
| | - Yaser M Alahmadi
- Department of Clinical and Hospital Pharmacy, College of Pharmacy, Taibah University, Madinah 42353, Saudi Arabia
| | - Sultan S Al Thagfan
- Department of Clinical and Hospital Pharmacy, College of Pharmacy, Taibah University, Madinah 42353, Saudi Arabia
| | - Sultan Alolayan
- Department of Clinical and Hospital Pharmacy, College of Pharmacy, Taibah University, Madinah 42353, Saudi Arabia
| | - Hossein M Elbadawy
- Department of Pharmacology and Toxicology, College of Pharmacy, Taibah University, Madinah 42353, Saudi Arabia
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Rimmele F, Janke J, Kropp P, Kasch R, Walter U, Jürgens TP. Headache in the Neurological Emergency Department—High Degree of Inadequate Documentation Calls for Structured Assessments. Front Neurol 2022; 13:847484. [PMID: 35401419 PMCID: PMC8987986 DOI: 10.3389/fneur.2022.847484] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2022] [Accepted: 02/15/2022] [Indexed: 11/13/2022] Open
Abstract
Headaches are a frequent reason for presentation to the emergency department (ED) and can pose a great challenge for the attending physicians. First and foremost, the distinction between a primary and secondary headache with potentially life-threatening implications can be difficult. Moreover, it often occurs that no specific headache diagnosis is made at discharge from the ED. Therefore, in this present retrospective cross-sectional study, all patients who presented to the emergency department of the Department of Neurology at Rostock University Medical Centre with the main symptom of headache between November 2013 and November 2016 underwent a neurological examination and the extent to which warning symptoms (“red flags”) for a secondary headache as well as symptoms necessary for a correct headache diagnosis according to the ICHD-3 classification were recorded and documented. We could show that documentation of red flags and clinical characteristics is inadequate and does not allow proper diagnostic categorization. To facilitate concise documentation and rapid decision making we suggest a structured and standardized form for documenting the headache history and red flags in the ED.
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Affiliation(s)
- Florian Rimmele
- Department of Neurology, Headache Center North-East, University Medical Center Rostock, Rostock, Germany
- *Correspondence: Florian Rimmele
| | - Josephine Janke
- Department of Neurology, Headache Center North-East, University Medical Center Rostock, Rostock, Germany
| | - Peter Kropp
- Institute of Medical Psychology and Medical Sociology, University Medical Center Rostock, Rostock, Germany
| | - Ramon Kasch
- Department of Neurology, KMG Klinikum Güstrow, Güstrow, Germany
| | - Uwe Walter
- Department of Neurology, Headache Center North-East, University Medical Center Rostock, Rostock, Germany
| | - Tim P. Jürgens
- Department of Neurology, Headache Center North-East, University Medical Center Rostock, Rostock, Germany
- Department of Neurology, KMG Klinikum Güstrow, Güstrow, Germany
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Yang S, Orlova Y, Lipe A, Boren M, Hincapie-Castillo JM, Park H, Chang CY, Wilson DL, Adkins L, Lo-Ciganic WH. Trends in the Management of Headache Disorders in US Emergency Departments: Analysis of 2007-2018 National Hospital Ambulatory Medical Care Survey Data. J Clin Med 2022; 11:jcm11051401. [PMID: 35268492 PMCID: PMC8910868 DOI: 10.3390/jcm11051401] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Revised: 02/18/2022] [Accepted: 02/28/2022] [Indexed: 12/10/2022] Open
Abstract
We examined trends in management of headache disorders in United States (US) emergency department (ED) visits. We conducted a cross-sectional study using 2007−2018 National Hospital Ambulatory Medical Care Survey data. We included adult patient visits (≥18 years) with a primary ED discharge diagnosis of headache. We classified headache medications by pharmacological group: opioids, butalbital, ergot alkaloids/triptans, acetaminophen/nonsteroidal anti-inflammatory drugs (NSAIDs), antiemetics, diphenhydramine, corticosteroids, and intravenous fluids. To obtain reliable estimates, we aggregated data into three time periods: 2007−2010, 2011−2014, and 2015−2018. Using multivariable logistic regression, we examined medication, neuroimaging, and outpatient referral trends, separately. Among headache-related ED visits, opioid use decreased from 54.1% in 2007−2010 to 28.3% in 2015−2018 (Ptrend < 0.001). There were statistically significant increasing trends in acetaminophen/NSAIDs, diphenhydramine, and corticosteroids use (all Ptrend < 0.001). Changes in butalbital (6.4%), ergot alkaloid/triptan (4.7%), antiemetic (59.2% in 2015−2018), and neuroimaging (37.3%) use over time were insignificant. Headache-related ED visits with outpatient referral for follow-up increased slightly from 73.3% in 2007−2010 to 79.7% in 2015−2018 (Ptrend = 0.02). Reflecting evidence-based guideline recommendations for headache management, opioid use substantially decreased from 2007 to 2018 among US headache-related ED visits. Future studies are warranted to identify strategies to promote evidence-based treatment for headaches (e.g., sumatriptan, dexamethasone) and appropriate outpatient referral and reduce unnecessary neuroimaging orders in EDs.
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Affiliation(s)
- Seonkyeong Yang
- Department of Pharmaceutical Outcomes & Policy, College of Pharmacy, University of Florida, Gainesville, FL 32611, USA; (S.Y.); (H.P.); (C.-Y.C.); (D.L.W.)
| | - Yulia Orlova
- Neurology Department, College of Medicine, University of Florida, Gainesville, FL 32611, USA;
| | - Abigale Lipe
- College of Pharmacy, University of Florida, Gainesville, FL 32611, USA; (A.L.); (M.B.)
| | - Macy Boren
- College of Pharmacy, University of Florida, Gainesville, FL 32611, USA; (A.L.); (M.B.)
| | - Juan M. Hincapie-Castillo
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA;
| | - Haesuk Park
- Department of Pharmaceutical Outcomes & Policy, College of Pharmacy, University of Florida, Gainesville, FL 32611, USA; (S.Y.); (H.P.); (C.-Y.C.); (D.L.W.)
- Center for Drug Evaluation and Safety, College of Pharmacy, University of Florida, Gainesville, FL 32611, USA
| | - Ching-Yuan Chang
- Department of Pharmaceutical Outcomes & Policy, College of Pharmacy, University of Florida, Gainesville, FL 32611, USA; (S.Y.); (H.P.); (C.-Y.C.); (D.L.W.)
| | - Debbie L. Wilson
- Department of Pharmaceutical Outcomes & Policy, College of Pharmacy, University of Florida, Gainesville, FL 32611, USA; (S.Y.); (H.P.); (C.-Y.C.); (D.L.W.)
| | - Lauren Adkins
- Health Science Center Libraries, University of Florida, Gainesville, FL 32611, USA;
| | - Wei-Hsuan Lo-Ciganic
- Department of Pharmaceutical Outcomes & Policy, College of Pharmacy, University of Florida, Gainesville, FL 32611, USA; (S.Y.); (H.P.); (C.-Y.C.); (D.L.W.)
- Center for Drug Evaluation and Safety, College of Pharmacy, University of Florida, Gainesville, FL 32611, USA
- Correspondence: ; Tel.: +1-352-273-6255
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Navarro-Pérez MP, Ballesta-Martínez S, Rodríguez-Montolio J, Bellosta-Diago E, García-Noaín JA, Santos-Lasaosa S. Acute migraine management in the emergency department: experience from a large Spanish tertiary hospital. Intern Emerg Med 2021; 16:2243-2249. [PMID: 33712966 DOI: 10.1007/s11739-021-02698-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Accepted: 03/05/2021] [Indexed: 10/21/2022]
Abstract
To assess the characteristics of the management of patients with migraine who present to the emergency department (ED) with a migraine attack. Retrospective, observational study analyzing demographic, clinical, diagnostic and therapeutic characteristics of patients with migraine diagnosis presenting to ED for a migraine attack between 2016 and 2019. We reviewed the clinical records of 847 cases. 82.2% were women with mean age of 34.9 years. 87.2% had episodic migraine and 12.2% chronic migraine. 62.3% (528/847) had taken analgesics before visiting the ED [non-steroidal-anti-inflammatory drugs (NSAIDs) (300/528; 56.9%) and triptans (261/528; 49.5%)]. 25.4% (215/847) received blood testing and 6.4% (55/847) received cranial CT. Medication was administered in 77.2% cases (654/847). The median time-to-treatment was 70 min (IQR 42-120). NSAIDs (81%, 530/654), antiemetics (43.1%, 282/654) and metamizole (39% 255/654) were the most used. Triptans were administered in 7 cases (1.1%) and opioids in 84 (12.8%). At discharge, preventive treatment was prescribed or modified in 8.2% of cases (69/839) and triptans were prescribed in 129 cases (15.3%). 70.5% (592/839) were instructed to follow-up with their primary care provider (PCP), 21.5% (181/839) with a general neurologist and 7.9% (66/839) with a headache specialist. The majority of migraine patients were not receiving the recommended acute migraine-specific medication, both in the outpatient and in the ED setting, being especially remarkable the rare use of triptans in the ED. Furthermore, we found an elevated use of urgent complementary tests, mainly blood tests.
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Affiliation(s)
- María Pilar Navarro-Pérez
- Neurology department, Hospital Clínico Universitario Lozano Blesa, San Juan Bosco 15, 50009, Zaragoza, Spain.
- Aragon Institute for Health Research (IIS Aragón), Zaragoza, Spain.
| | - Sara Ballesta-Martínez
- Neurology department, Hospital Clínico Universitario Lozano Blesa, San Juan Bosco 15, 50009, Zaragoza, Spain
| | - Joana Rodríguez-Montolio
- Neurology department, Hospital Clínico Universitario Lozano Blesa, San Juan Bosco 15, 50009, Zaragoza, Spain
| | - Elena Bellosta-Diago
- Neurology department, Hospital Clínico Universitario Lozano Blesa, San Juan Bosco 15, 50009, Zaragoza, Spain
- Aragon Institute for Health Research (IIS Aragón), Zaragoza, Spain
| | | | - Sonia Santos-Lasaosa
- Neurology department, Hospital Clínico Universitario Lozano Blesa, San Juan Bosco 15, 50009, Zaragoza, Spain
- Aragon Institute for Health Research (IIS Aragón), Zaragoza, Spain
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Rimmele F, Janke J, Kropp P, Grossmann A, Hamann T, Walter U, Jürgens TP. Headache Characteristics in the Neurological Emergency Department: A Retrospective Study. Front Neurol 2021; 12:706074. [PMID: 34489852 PMCID: PMC8416997 DOI: 10.3389/fneur.2021.706074] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Accepted: 07/28/2021] [Indexed: 01/29/2023] Open
Abstract
Background: The care of patients with headache in the emergency department (ED) represents a diagnostic and clinical challenge. Data on the prevalence and characteristics of headache patients in purely neurological EDs are sparse. The aim of the present study is to examine patient profiles with the cardinal symptom of headache in an academic neurological ED, to analyze correlations between headache characteristics and search for differences compared to the interdisciplinary ED. Methods: This retrospective cross-sectional study assessed all patients who presented to the ED of the Department of Neurology at Rostock University Medical Center between November 2013 and November 2016 with the main symptom of headache. Epidemiological, clinical, diagnostic data as well as key data regarding the care structure were recorded. Correlations between headache characteristics and diagnosis at discharge were analyzed and risk profiles were identified using binary logistic regression analysis. Conclusion: This study comprehensively characterized a large collective of patients with the cardinal symptom of headache presenting to a purely neurology emergency department.
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Affiliation(s)
- Florian Rimmele
- Department of Neurology, Headache Center North-East, University Medical Center Rostock, Rostock, Germany
| | - Josephine Janke
- Department of Neurology, Headache Center North-East, University Medical Center Rostock, Rostock, Germany
| | - Peter Kropp
- Institute of Medical Psychology and Medical Sociology, University Medical Center Rostock, Rostock, Germany
| | - Annette Grossmann
- Institute of Diagnostic and Interventional Radiology, Pediatric Radiology and Neuroradiology, University Medical Center Rostock, Rostock, Germany
| | - Till Hamann
- Department of Neurology, Headache Center North-East, University Medical Center Rostock, Rostock, Germany
| | - Uwe Walter
- Department of Neurology, Headache Center North-East, University Medical Center Rostock, Rostock, Germany
| | - Tim P Jürgens
- Department of Neurology, Headache Center North-East, University Medical Center Rostock, Rostock, Germany
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Luciani M, Negro A, Spuntarelli V, Bentivegna E, Martelletti P. Evaluating and managing severe headache in the emergency department. Expert Rev Neurother 2021; 21:277-285. [PMID: 33297780 DOI: 10.1080/14737175.2021.1863148] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Introduction: Headache is the fifth most common reason to visit an emergency department (ED). In most of the cases, headache is benign and has a primary origin, with migraine as the most common diagnosis. Inappropriate use of ED for non-emergency conditions causes overcrowding, unnecessary testing, and increased medical costs.Areas covered: All stages of headache management in ED, from the reasons to go there, the diagnosis that is made and the investigations necessary to make it, to get to the therapies administered and those prescribed at discharge, if there were any. Finally, the authors evaluated the habit of recommending medical follow-up and how often the headache is still present at discharge or returns within 24 hours.Expert Opinion: Primary headaches are underdiagnosed, misdiagnosed, and the majority do not receive drug therapy either in ED or on discharge, and in cases where the therapy is prescribed is not specific. Increase the number of primary care medical services, spread the 'headaches culture' among GPs and ED doctors, the adoption of ICHD in the diagnostic protocols used in EDs and a fast referral to a headache center could decrease the inappropriate use of ED and improve the headache management in the emergency units.
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Affiliation(s)
| | - Andrea Negro
- Department of Clinical and Molecular Medicine, Sapienza University, Rome, Italy.,Regional Referral Headache Centre, Sant'Andrea Hospital, Rome, Italy
| | - Valerio Spuntarelli
- Department of Clinical and Molecular Medicine, Sapienza University, Rome, Italy
| | - Enrico Bentivegna
- Department of Clinical and Molecular Medicine, Sapienza University, Rome, Italy
| | - Paolo Martelletti
- Department of Clinical and Molecular Medicine, Sapienza University, Rome, Italy.,Regional Referral Headache Centre, Sant'Andrea Hospital, Rome, Italy
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Wang PR, Lopez R, Seballos SS, Campbell MJ, Udeh BL, Phelan MP. Management of migraine in the emergency department: Findings from the 2010-2017 National Hospital Ambulatory Medical Care Surveys. Am J Emerg Med 2021; 41:40-45. [PMID: 33385884 DOI: 10.1016/j.ajem.2020.12.056] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Accepted: 12/18/2020] [Indexed: 01/01/2023] Open
Abstract
OBJECTIVE The study objective was to describe trends in the medical management of migraine in the emergency department (ED) using the 2010-2017 National Hospital Ambulatory Medical Care Survey (NHAMCS) datasets. METHODS Using the 2010-2017 NHAMCS datasets, we analyzed visits with a discharge diagnosis of migraine. Drug prescription frequencies between years were compared with the Rao-Scott chi-squared test. Adjusted odds ratios of opioid administration from 2010 to 2017 were calculated using weighted multivariable logistic regression with sex, age, race/ethnicity, pain-score, primary expected source of payment, and year as predictor variables. RESULTS Our analysis captured 1846 ED visits with a diagnosis of migraine from 2010 to 2017, representing a weighted average of 1.2 million US ED visits per year. Parenteral opioids were prescribed in 49% (95% CI: 40, 58) of visits in 2010 and 28% (95% CI: 15, 45) of visits in 2017 (p = 0.03). From 2010 to 2017, there was a 10% yearly decrease in opioid prescriptions. Metoclopramide and ketorolac were prescribed more frequently in years 2015 through 2017 than in 2010. Increased opioid administration was associated with female sex, older age, white race, higher pain score, and having Medicare or private insurance as the primary expected source of payment for all years. CONCLUSION Opioid administration for migraine in EDs across the US declined 10% annually between 2010 and 2017, demonstrating improved adherence to migraine guidelines recommending against opioids. We identified several factors associated with opioid administration for migraine, identifying groups at higher risk for unnecessary opioids in the ED setting.
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Affiliation(s)
- Philip R Wang
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH, United States of America.
| | - Rocio Lopez
- Center for Populations Health Research, Cleveland Clinic, Cleveland, OH, United States of America; Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH, United States of America
| | - Spencer S Seballos
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH, United States of America
| | - Matthew J Campbell
- Department of Pharmacy, Cleveland Clinic, Cleveland, OH, United States of America
| | - Belinda L Udeh
- Center for Populations Health Research, Cleveland Clinic, Cleveland, OH, United States of America; Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH, United States of America; Neurological Institute Center for Outcomes Research, Cleveland Clinic, Cleveland, OH, United States of America
| | - Michael P Phelan
- Emergency Services Institute, Cleveland Clinic, Cleveland, OH, United States of America
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Krymchantowski A, Jevoux C, Silva‐Néto RP, Krymchantowski AG. Migraine Treatment in Emergency Departments of Brazil: A Retrospective Study of 2 Regions. Headache 2020; 60:2413-2420. [DOI: 10.1111/head.13999] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Revised: 05/04/2020] [Accepted: 05/04/2020] [Indexed: 01/03/2023]
Affiliation(s)
| | - Carla Jevoux
- Department of Neurology Headache Center of Rio Rio de Janeiro Brazil
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Abstract
Migraine is a frequently disabling neurologic condition which can be complicated by medication overuse headache and comorbid medical disorders, including obesity, anxiety and depression. Although most migraine management takes place in outpatient clinics, inpatient treatment is indicated for migraine refractory to multiple outpatient treatments, with intractable nausea or vomiting, need for detoxification from medication overuse (such as opioids and barbiturates), and significant medical and psychiatric disease. The goals of inpatient treatment include breaking the current cycle of headache pain, reducing the frequency and/or severity of future attacks, monitored detoxification of overused medications, and reducing disability and improving quality of life.
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Affiliation(s)
- Michael J Marmura
- Thomas Jefferson University, Jefferson Headache Center, 900 Walnut Street #200, Philadelphia, PA 19107, USA.
| | - Angela Hou
- Thomas Jefferson University, Jefferson Headache Center, 900 Walnut Street #200, Philadelphia, PA 19107, USA. https://twitter.com/JeffHeadacheCtr
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12
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Negro A, Spuntarelli V, Sciattella P, Martelletti P. Rapid referral for headache management from emergency department to headache centre: four years data. J Headache Pain 2020; 21:25. [PMID: 32169031 PMCID: PMC7071765 DOI: 10.1186/s10194-020-01094-6] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2020] [Accepted: 03/06/2020] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Headache is one of the most common reason for medical consultation to emergency department (ED). The inappropriate use of ED for non-emergency conditions is a problem in terms of overcrowding of emergency facilities, unnecessary testing and treatment, increased medical costs, burden on medical service providers and weaker relationships between patient and primary care provider. The aim of this study was to analyze the different stages of ED management of headache to identify those deficiencies that can be overcome by a fast referral to a headache clinic. METHODS The study is a retrospective analysis of the electronic medical records of patients discharged from an academic ED between January 1, 2015 and December 31, 2018 and referred to the tertiary level headache centre of the same hospital. We analyzed all aspects related to the permanence in ED and also assessed whether there was a match between the diagnosis made in ED and ours. RESULTS Among our sample of 244 patients, 76.2% were admitted as "green tag", 75% underwent a head computed tomography, 19.3% received a neurological consultation, 43% did not receive any pharmacological treatment and 62.7% still had headache at discharge. The length of stay in ED was associated with reporting the first aura ever (p = 0.014) and whether patients received consultations (p < 0.001). The concordance analysis shown a significant moderate agreement only for the diagnosis of migraine and only between triage and headache centre. CONCLUSIONS Most patients who went to ED complaining of headache received the same treatment regardless of their diagnosis and in many cases the headache had not yet resolved at the time of discharge. Given the many shortcomings in headache management in ED, rapid referral to the headache centre is of paramount importance to help the patient achieve a definiteve diagnosis and appropriate treatment.
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Affiliation(s)
- Andrea Negro
- Department of Clinical and Molecular Medicine, Sapienza University, Rome, Italy.
- Regional Referral Headache Centre, Sant'Andrea Hospital, Rome, Italy.
| | - Valerio Spuntarelli
- Department of Clinical and Molecular Medicine, Sapienza University, Rome, Italy
| | - Paolo Sciattella
- Department of Statistical Sciences, Sapienza University of Rome, Rome, Italy
| | - Paolo Martelletti
- Department of Clinical and Molecular Medicine, Sapienza University, Rome, Italy
- Regional Referral Headache Centre, Sant'Andrea Hospital, Rome, Italy
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Minen MT, Zhou K, Miller L. A Brief Look at Urgent Care Visits for Migraine: The Care Received and Ideas to Guide Migraine Care in this Proliferating Medical Setting. Headache 2020; 60:542-552. [PMID: 31802490 PMCID: PMC8640612 DOI: 10.1111/head.13717] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/08/2019] [Indexed: 12/12/2022]
Abstract
OBJECTIVE There has been a rise in urgent care centers throughout the country over the past 10 years, leading to an increase in patients accessing medical care in these locations. These centers advertise an alternative to the Emergency Department (ED) for the evaluation and treatment of urgent medical conditions. The goal of this analysis was to examine the use of urgent care visits for migraine within 2 urgent care centers within a large academic medical system in New York City. We examined the trends in management and treatment of migraine in these urgent care settings, as well as prescriptions and instructions given to this patient population upon discharge. We paid particular attention to whether the medications administered and prescribed on discharge were those recommended by American Headache Society migraine management guidelines. METHODS We conducted a retrospective chart review of patients with migraine diagnoses at 2 different urgent care locations within 1 large urban medical center. We determined baseline patient demographics, previous migraine characteristics, frequencies of reasons for urgent care visits as well as various medications administered, medications prescribed on discharge, and characteristics of patient outcomes post-discharge. RESULTS Of the 78 patients who visited urgent care with a migraine diagnosis, 20 (25.6%) had a known primary care provider within the urgent care centers' healthcare system. More than three-fourths of all patients (78.2%) had a self-reported history of either recurrent headache or migraine prior to the urgent care visit. Of those with a documented frequency of prior headaches, 94.1% (32/34) had episodic migraine and 79.4% (27/34) experienced at most 1-2 headache days per month. Of those presenting to the urgent care during an episode of migraine, 12.3% (9/73) were given intravenous metoclopramide and none were given subcutaneous sumatriptan or intravenous prochlorperazine. Of those with reported nausea or vomiting with their migraine, 46.2% (18/39) received an anti-emetic at the visit and 33.3% (13/39) were given an anti-emetic prescription. Only 11.1% (6/54) of patients who did not have a record of previous triptan use were given a triptan prescription at the urgent care visit. CONCLUSIONS The majority of patients in our study who sought medical treatment for migraine in these 2 urgent care centers were not established patients within the urgent care centers' healthcare system. While 93.6% (73/78) of patients were experiencing current pain upon presentation to the urgent care centers, only 12.3% (9/73) received administration of the medications with the highest level of evidence by the American Headache Society (Level B) for acute migraine treatment in an ED. In addition, the majority of patients with a migraine history presenting to the urgent care setting were not given triptans or anti-emetic prescriptions upon discharge from their urgent care visit. Having these migraine-specific prescriptions may improve self-treatment at home should a migraine attack recur.
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Affiliation(s)
- Mia T Minen
- Department of Neurology and Population Health, NYU Langone Health, New York, NY, USA
| | - Kina Zhou
- School of Medicine, University of Rochester, Rochester, NY, USA
| | - Leslie Miller
- Department of Emergency Medicine, NYU Langone Health, New York, NY, USA
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Giamberardino MA, Affaitati G, Costantini R, Guglielmetti M, Martelletti P. Acute headache management in emergency department. A narrative review. Intern Emerg Med 2020; 15:109-117. [PMID: 31893348 DOI: 10.1007/s11739-019-02266-2] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2019] [Accepted: 12/17/2019] [Indexed: 12/12/2022]
Abstract
Headache is a significant reason for access to Emergency Departments (ED) worldwide. Though primary forms represent the vast majority, the life-threatening potential of secondary forms, such as subarachnoid hemorrage or meningitis, makes it imperative for the ED physician to rule out secondary headaches as first step, based on clinical history, careful physical (especially neurological) examination and, if appropriate, hematochemical analyses, neuroimaging or lumbar puncture. Once secondary forms are excluded, distinction among primary forms should be performed, based on the international headache classification criteria. Most frequent primary forms motivating ED observation are acute migraine attacks, particularly status migrainous, and cluster headache. Though universally accepted guidelines do not exist for headache management in an emergency setting, pharmacological parenteral treatment remains the principal approach worldwide, with NSAIDs, neuroleptic antinauseants, triptans and corticosteroids, tailored to the specific headache type. Opioids should be avoided, for their scarce effectiveness in the acute phase, while IV hydration should be limited in cases of ascertained dehydration. Referral of the patient to a Headache Center should subsequently be an integral part of the ED approach to the headache patients, being ascertained that lack of this referral involves a high rate of relapse and new accesses to the ED. More controlled studies are needed to establish specific protocols of management for the headache patient in the ED.
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Affiliation(s)
- Maria Adele Giamberardino
- Headache Center, Geriatrics Clinic, Department of Medicine and Science of Aging and Ce.S.I.-Met, G. D'Annunzio University of Chieti, 66100, Chieti, Italy
| | - Giannapia Affaitati
- Headache Center, Geriatrics Clinic, Department of Medicine and Science of Aging and Ce.S.I.-Met, G. D'Annunzio University of Chieti, 66100, Chieti, Italy
| | - Raffaele Costantini
- Institute of Surgical Pathology, G. D'Annunzio University of Chieti, Chieti, Italy
| | - Martina Guglielmetti
- Department of Clinical Pathology, University of Sassari, Sassari, Italy
- Department of Clinical and Molecular Medicine, Sapienza University, Via di Grottarossa, 1035, 00189, Rome, Italy
| | - Paolo Martelletti
- Department of Clinical and Molecular Medicine, Sapienza University, Via di Grottarossa, 1035, 00189, Rome, Italy.
- UOC Medicina Interna, AOU Sant'Andrea, Rome, Italy.
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Platzbecker K, Zhang MB, Kurth T, Rudolph MI, Eikermann-Haerter K, Burstein R, Eikermann M, Houle T. The association between migraine and hospital readmission due to pain after surgery: A hospital registry study. Cephalalgia 2019; 39:286-295. [PMID: 29984600 PMCID: PMC7192134 DOI: 10.1177/0333102418786457] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Migraine has been identified as a risk factor of 30-day hospital readmission after surgery. We aimed to further characterize this association examining pain as a potentially migraine-associated, preventable reason for readmission. HYPOTHESIS Compared to patients with no migraine, surgical patients with migraine are at increased risk of 30-day hospital readmission with an admitting diagnosis specifying pain. METHODS This hospital registry study examined 150,710 patients aged 18 years and above, who underwent surgery with general anesthesia and mechanical ventilation between 2007 and 2015 at a tertiary care center and two affiliated community hospitals in Massachusetts, USA. RESULTS Migraine was associated with an increased risk of 30-day pain-related readmission after surgery (adjusted odds ratio 1.42 [95% confidence interval 1.15-1.75]). The association was stronger for migraine with aura (compared to migraine without aura: Adjusted odds ratio 1.69 [95% confidence interval 1.06-2.70]; compared to no migraine: Adjusted odds ratio 2.20 [95% confidence interval 1.44-3.37]). The predicted adjusted risk of pain-related 30-day readmissions was 9.1 [95% confidence interval 5.3-13.0] in 1000 surgical patients with migraine with aura and 5.4 [95% confidence interval 4.2-6.6] in 1000 patients with migraine without aura, compared to 4.2 [95% confidence interval 3.8-4.5] in 1000 patients with no migraine. Furthermore, migraine was associated with an increased risk of postsurgical 30-day readmission due to a priori defined migraine-related pain (headache or abdominal pain) (adjusted odds ratio 1.55 [95% confidence interval 1.20-2.00]). CONCLUSION Patients with migraine undergoing surgery are at increased risk of 30-day hospital readmission due to pain.
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Affiliation(s)
- Katharina Platzbecker
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
| | - Megan Behua Zhang
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Tobias Kurth
- Institute of Public Health, Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Maira Isabella Rudolph
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | | | - Rami Burstein
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
| | - Matthias Eikermann
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
- Klinik für Anästhesiologie und Intensivmedizin, Universitätsklinikum Essen, Essen, Germany
| | - Timothy Houle
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
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Karri J, Abd-Elsayed A. Dihydroergotamine Infusion Therapy. INFUSION THERAPY 2019:95-105. [DOI: 10.1007/978-3-030-17478-1_7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/01/2023]
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Todd KH. A Review of Current and Emerging Approaches to Pain Management in the Emergency Department. Pain Ther 2017; 6:193-202. [PMID: 29127600 PMCID: PMC5693816 DOI: 10.1007/s40122-017-0090-5] [Citation(s) in RCA: 54] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2017] [Indexed: 01/08/2023] Open
Abstract
INTRODUCTION Pain is the most common symptom prompting an emergency department visit and emergency physicians are responsible for managing both acute pain and acute exacerbations of chronic pain resulting from a broad range of illnesses and injuries. The responsibility to treat must be balanced by the duty to limit harm resulting from analgesics. In recent years, opioid-related adverse effects, including overdose and deaths, have increased dramatically in the USA. In response to the US opioid crisis, emergency physicians have broadened their analgesic armamentarium to include a variety of non-opioid approaches. For some of these therapies, sparse evidence exists to support their efficacy for emergency department use. The purpose of this paper is to review historical trends and emerging approaches to emergency department analgesia, with a particular focus on the USA and Canada. METHODS We conducted a qualitative review of past and current descriptive studies of emergency department pain practice, as well as clinical trials of emerging pain treatment modalities. The review considers the increasing use of non-opioid and multimodal analgesic therapies, including migraine therapies, regional anesthesia, subdissociative-dose ketamine, nitrous oxide, intravenous lidocaine and gabapentinoids, as well as broad programmatic initiatives promoting the use of non-opioid analgesics and nonpharmacologic interventions. RESULTS While migraine therapies, regional anesthesia, nitrous oxide and subdissociative-dose ketamine are supported by a relatively robust evidence base, data supporting the emergency department use of intravenous lidocaine, gabapentinoids and various non-pharmacologic analgesic interventions remain sparse. CONCLUSION Additional research on the relative safety and efficacy of non-opioid approaches to emergency department analgesia is needed. Despite a limited research base, it is likely that non-opioid analgesic modalities will be employed with increasing frequency. A new generation of emergency physicians is seeking additional training in pain medicine and increasing dialogue between emergency medicine and pain medicine researchers, educators and clinicians could contribute to better management of emergency department pain.
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Minen MT, Boubour A, Wahnich A, Grudzen C, Friedman BW. A Retrospective Nested Cohort Study of Emergency Department Revisits for Migraine in New York City. Headache 2017; 58:399-406. [DOI: 10.1111/head.13216] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2017] [Revised: 09/06/2017] [Accepted: 09/06/2017] [Indexed: 11/29/2022]
Affiliation(s)
| | | | - Amanda Wahnich
- New York City Department of Health and Mental Hygiene; New York NY USA
| | - Corita Grudzen
- Department of Emergency Medicine; NYU Langone Medical Center; New York NY USA (C. Grudzen)
| | - Benjamin W. Friedman
- Department of Emergency Medicine; Albert Einstein College of Medicine; New York NY USA
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Friedman BW, Vinson DR. Convincing the skeptic. How to fix emergency department headache management. Cephalalgia 2014; 35:641-3. [DOI: 10.1177/0333102414557704] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Benjamin W Friedman
- Department of Emergency Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, USA
| | - David R Vinson
- Department of Emergency Medicine, Kaiser Permanente Sacramento Medical Center, USA
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Friedman BW, West J, Vinson DR, Minen MT, Restivo A, Gallagher EJ. Current management of migraine in US emergency departments: An analysis of the National Hospital Ambulatory Medical Care Survey. Cephalalgia 2014; 35:301-9. [DOI: 10.1177/0333102414539055] [Citation(s) in RCA: 67] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Background Published data from 1998 revealed that most patients treated for migraine in an emergency department received opioids. Over the intervening years, a large body of evidence has emerged demonstrating the efficacy and safety of non-opioid alternatives. Expert opinion during these years has cautioned against use of opioids for migraine. Our objectives were to compare current frequency of use of various medications for acute migraine in US emergency departments with use of these same medications in 1998 and to identify factors independently associated with opioid use. Methods We analyzed National Hospital Ambulatory Medical Care Survey data from 2010, the most current dataset available. The National Hospital Ambulatory Medical Care Survey is a public dataset collected and distributed by the Centers for Disease Control and Prevention. It is a multi-stage probability sample from randomly selected emergency departments across the country, designed to be representative of all US emergency department visits. We included in our analysis all patients with the ICD9 emergency department discharge diagnosis of migraine. We tabulated frequency of use of specific medications in 2010 and compared these results with the 1998 data. Using a logistic regression model, into which all of the following variables were entered, we explored the independent association between any opioid use in 2010 and sex, age, race/ethnicity, geographic region, type of hospital, triage pain score and history of emergency department use within the previous 12 months. Results In 2010, there were 1.2 (95% confidence interval 0.9, 1.4) million migraine visits to US emergency departments. Including opioid-containing oral analgesic combinations, opioids were administered in 59% of visits (95% confidence interval 51, 67). The most commonly used parenteral agent, hydromorphone, was used in 25% (95% confidence interval 19, 33) of visits in 2010 versus less than 1% (95% confidence interval 0, 3) in 1998. Conversely, use of meperidine had decreased markedly over the same timeframe. In 2010, it was used in just 7% (95% confidence interval 4, 12) of visits compared to 37% (95% confidence interval 29, 45) in 1998. Metoclopramide, the most commonly used anti-dopaminergic, was administered in 17% (95% confidence interval 12, 23) of visits in 2010 and 3% (95% confidence interval 1, 6) of visits in 1998. Use of any triptan was relatively uncommon in 2010 (7% (95% confidence interval 4, 11) of visits) and in 1998 (10% (95% confidence interval 6, 15) of visits). Of the predictor variables listed above, only emergency department use within the previous 12 months was associated with opioid administration (adjusted odds ratio: 2.87 (95% confidence interval 1.03, 7.97)). Conclusions In spite of recommendations to the contrary, opioids are still used in more than half of all emergency department visits for migraine. Though use of meperidine has decreased markedly between 1998 and 2010, it has largely been replaced by hydromorphone. Opioid use in migraine visits is independently associated with prior visits to the same emergency department in the previous 12 months.
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Affiliation(s)
- Benjamin W Friedman
- Department of Emergency Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, NY, USA
| | - Jason West
- Department of Emergency Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, NY, USA
| | - David R Vinson
- Department of Emergency Medicine, Kaiser Permanente Sacramento Medical Center, CA, USA
| | - Mia T Minen
- John Graham Headache Center, Department of Neurology, Brigham and Women’s Faulkner Hospital and Harvard Medical School, MA, USA
| | - Andrew Restivo
- Department of Emergency Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, NY, USA
| | - E John Gallagher
- Department of Emergency Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, NY, USA
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Minen MT, Tanev K, Friedman BW. Evaluation and treatment of migraine in the emergency department: a review. Headache 2014; 54:1131-45. [PMID: 24898930 DOI: 10.1111/head.12399] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/17/2014] [Indexed: 11/28/2022]
Abstract
Head pain is the fifth most common reason for emergency department (ED) visits. It is second only to focal weakness as the most common reason for neurological consultation in the ED. This manuscript reviews how patients with migraine, the most common primary headache disorder for which patients seek medical treatment, are managed in the ED. We discuss existing guidelines for head imaging in patients with migraine, recommended pharmacologic treatments, and current treatment trends. We also review studies evaluating the discharge care of migraine patients in the ED. With the goal of standardizing, streamlining, and optimizing ED-based migraine care, we offer ideas for future research to improve the evaluation, treatment, and discharge care of patients who present to an ED with acute migraine.
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Affiliation(s)
- Mia T Minen
- Graham Headache Center, Department of Neurology, Brigham and Women's Faulkner Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
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Eapen A, Agarwal R, Thomas R, Sivaswamy L. Management of pediatric migraine in a tertiary care versus community based emergency department: an observational pilot study. Pediatr Neurol 2014; 50:164-70. [PMID: 24321543 DOI: 10.1016/j.pediatrneurol.2013.10.005] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2013] [Revised: 10/03/2013] [Accepted: 10/12/2013] [Indexed: 10/26/2022]
Abstract
BACKGROUND Because of a lack of guidelines for the management of pediatric migraine in the emergency department setting, marked variations in treatment protocols exist between institutions. We aimed to characterize differences in management strategies for pediatric migraine treatment between a community-based and a tertiary care emergency department. METHODS A retrospective cohort study was performed to include pediatric patients presenting with headache fulfilling the International Classification of Headache Disorders-2 migraine criteria in a tertiary care (site 1) and a community based (site 2) emergency department. The two sites were compared with respect to patient demographics and approach to treatment. RESULTS A total of 158 patients at site 1 (mean age 13.6 years, 70% female, 68% African-American) and 63 patients at site 2 (mean age 16.7 years, 71% female, 100% Caucasian) were analyzed. Opiate use (7.6% vs. 33%), imaging (6.3% vs. 20.6%), use of nonsteroidal anti-inflammatory drugs/serotonin agonists at discharge (72.7% vs. 22.2%), and admission rates to hospital (22% vs. 0%) were significantly different. Logistic regression analysis indicated that the main predictors of hospital admission were use of opiates and intravenous combination abortive therapy. CONCLUSION Low rates of intravenous combination therapy, antidopaminergic agent, and serotonin agonist use were noted across both hospital settings. Community-based physicians used opiates and obtained neuro-imaging more than those in the academic setting. Standardization of care in the emergency setting coupled with reliable acute care plans that are based on evidenced-based guidelines can allow for better control of episodic migraine and reduce emergency department visits.
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Affiliation(s)
- Amy Eapen
- Wayne State University School of Medicine, Detroit, Michigan
| | - Rajkumar Agarwal
- Department of Pediatrics and Neurology, Children's Hospital of Michigan and Wayne State University School of Medicine, Detroit, Michigan.
| | - Ronald Thomas
- Department of Biostatistics, Children's Hospital of Michigan and Wayne State University School of Medicine, Detroit, Michigan
| | - Lalitha Sivaswamy
- Department of Pediatrics and Neurology, Children's Hospital of Michigan and Wayne State University School of Medicine, Detroit, Michigan
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Saengcharoen W, Lerkiatbundit S. Migraine management in community pharmacies: practice patterns and knowledge of pharmacy personnel in Thailand. Headache 2013; 53:1451-63. [PMID: 23808927 DOI: 10.1111/head.12163] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/16/2013] [Indexed: 11/30/2022]
Abstract
OBJECTIVES To describe practice behavior and understanding among pharmacy personnel, both pharmacists and non-pharmacist staff, in the management of mild and moderate migraines. BACKGROUND Migraine is recognized as a prevalent and chronic neurological disorder. In developing countries, such as Thailand, community pharmacies are a widely used source of health care for various illnesses including migraine. However, the quality of migraine management and knowledge among pharmacy personnel is unclear. METHODS Cross-sectional study. The sample comprised 142 randomly selected community pharmacies in a city in the south of Thailand. Simulated clients visited the pharmacies twice, at least 1 month apart, to ask for the treatment of mild and moderate migraines. After the encounters, question asking, drug dispensing, and advice giving by pharmacy staff were recorded. Subsequently, the providers in 135 pharmacies participated in the interview to evaluate their knowledge in migraine management. RESULTS The majority of pharmacy personnel were less likely to ask questions in cases of mild migraine when compared with moderate attack (mean score [full score = 12] 1.8 ± 1.6 vs 2.6 ± 1.5, respectively, P < 0.001). Mean difference of question asking between mild and moderate migraines was -0.8 (95% confidence interval -1.1 to -0.5, P < 0.001). Approximately 33% and 54% of the providers appropriately dispensed non-steroidal anti-inflammatory drugs for mild attack and ergotamine for moderate migraine, respectively, P < 0.001. Prophylactic medications (eg, atenolol, propranolol, flunarizine) were inappropriately recommended, particularly in moderate attack (28.2% vs 17.6% in mild migraine, P = 0.018). Less than 30% of providers advised the patients on the maximum limit of dose or discontinuity of medications when recovered. Compared with non-pharmacists, pharmacists tended to ask more questions, give more advice, and dispense less appropriately; however, there were no significant differences. The results from the interview showed that most pharmacy personnel had inadequate knowledge on migraine management. Pharmacists had better knowledge on question asking (mild migraine 5.1 ± 2.1 vs 3.1 ± 1.3, respectively, P < .001; moderate disorder 6.5 ± 3.1 vs 3.9 ± 2.1, respectively, P < .001) and tended to have more knowledge on advice giving but poorer drug dispensing in moderate migraine according to the guidelines, relative to non-pharmacists (20.5% vs 40.3%, P = .014). CONCLUSIONS A large number of community pharmacists and non-pharmacist staff had inappropriate practice behavior and understanding. Continuing education and interventions are important to improve the practice and knowledge of pharmacy personnel, particularly the pharmacists.
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Affiliation(s)
- Woranuch Saengcharoen
- Department of Clinical Pharmacy, Faculty of Pharmaceutical Sciences, Prince of Songkla University, Hat Yai, Songkhla, Thailand
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Kelley NE, Tepper DE. Rescue therapy for acute migraine, part 1: triptans, dihydroergotamine, and magnesium. Headache 2011; 52:114-28. [PMID: 22211870 DOI: 10.1111/j.1526-4610.2011.02062.x] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To review and analyze published reports on the acute treatment of migraine headache with triptans, dihydroergotamine (DHE), and magnesium in emergency department, urgent care, and headache clinic settings. METHODS MEDLINE was searched using the terms "migraine" and "emergency," and "therapy" or "treatment." Reports from emergency department and urgent care settings that involved all routes of medication delivery were included. Reports from headache clinic settings were included only if medications were delivered by a parenteral route. RESULTS Acute rescue treatment studies involving the triptans were available for injectable and nasal sumatriptan, as well as rizatriptan. Effectiveness varied widely, even when the pain-free and pain-relief statistics were evaluated separately. As these medications are known to work best early in the migraine, part of this variability may be attributed to the timing of triptan administration. Multiple studies compared triptans with anti-emetics, dopamine antagonists, and non-steroidal anti-inflammatory drugs. The overall percentage of patients with pain relief after taking sumatriptan was roughly equivalent to that recorded with droperidol and prochlorperazine. Sumatriptan was equivalent to DHE when only paired comparisons were performed. While the data extracted suggest that magnesium may be effective in treating all symptoms in patients experiencing migraine with aura across all migraine patients, its effectiveness seems to be limited to treating only photophobia and phonophobia. CONCLUSIONS Although there are relatively few studies involving health-care provider-administered triptans or DHE for acute rescue, they appear to be equivalent to the dopamine antagonists for migraine pain relief. The relatively rare inclusion of a placebo arm and the frequent use of combination medications in active treatment arms complicate the comparison of single agents with each other.
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Affiliation(s)
- Nancy E Kelley
- Center for Headache and Pain, Neurological Institute, Cleveland Clinic, Cleveland, Ohio 44195, USA
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Abstract
BACKGROUND Despite advances in treatment, patients with migraine have been underdiagnosed and undertreated, specifically in emergency departments. In addition, great variability exists with respect to the diagnosis, management and treatment of migraine patients in emergency departments. In particular, migraine-specific treatments, including serotonin receptor agonists, appear to be rarely used. OBJECTIVE To examine the diagnosis and management of migraine patients within Ontario emergency departments. METHODS A prospective survey was designed to inquire how emergency physicians diagnose and manage patients with migraine. Questions focused on the use of serotonin receptor agonists, the rationale behind their use or nonuse, and acute headache protocols. The survey also inquired about the use of International Classification Of Headache Disorders-2 criteria in diagnosing migraine by emergency physicians, medication prescribed on discharge, and referrals made to outpatient specialists. These surveys were distributed to and anonymously completed by emergency physicians in several departments in Ontario. RESULTS Migraine-specific treatments were underused in emergency departments. Furthermore, many departments lacked headache protocols and, often, migraine-specific treatment was not included in the few departments with protocols. CONCLUSIONS Diagnosis and management of migraines can be improved within emergency departments, and patients can be more effectively channelled toward appropriate outpatient care.
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Landy SH, Kaniecki RG, Taylor FR. Abstracts and Citations. Headache 2011. [DOI: 10.1111/j.1526-4610.2011.01950.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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28
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Kaniecki RG, Taylor FR, Landy SH. Abstracts and Citations. Headache 2010. [DOI: 10.1111/j.1526-4610.2010.01750.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Valade D, Lucas C, Calvel L, Plaisance P, Derouet N, Meric G, Lanteri-Minet M, Giroud M. Migraine diagnosis and management in general emergency departments in France. Cephalalgia 2010; 31:471-80. [DOI: 10.1177/0333102410378178] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background We conducted a prospective study of patients admitted to 22 general emergency departments in France over 1 week. Patients and methods Of 15,835 adult patients, 483 (3.1%) had headache and 98 (0.6%) had migraine. Results Compared with the migraine population in France, our migraine patients were similar in terms of proportion of female patients (75%) and mean age (37.6 ± 13.8 years) but presented earlier in their disease course. Patients sought emergency treatment because of a severe attack (49%) or because of ineffective treatment (20%). Non-opioid analgesics excluding non-steroidal anti-inflammatory drugs (NSAIDs), and NSAIDs, were most commonly prescribed as acute treatment, yet it took more than 48 h for symptom resolution in 36% of 92 follow-up patients. Conclusions Results suggest there is room for improvement in choice of agents prescribed. We propose additional education and training of clinicians to improve adherence to clinical practice guidelines.
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Affiliation(s)
| | | | | | | | | | | | | | - M Giroud
- Centre Hospitalier René Dubos, France
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Management of primary headaches in adult Emergency Departments: a literature review, the Parma ED experience and a therapy flow chart proposal. Neurol Sci 2010; 31:545-53. [PMID: 20614150 DOI: 10.1007/s10072-010-0337-y] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2008] [Accepted: 05/22/2010] [Indexed: 10/19/2022]
Abstract
Adults seeking treatment at hospitals' Emergency Departments (EDs) because of headache represent a major health-care issue. To date, there are no special guidelines for management of primary headache in adults seen at EDs and therapeutic approaches are often inconsistent. This review describes the therapeutic strategies that are most frequently used to treat primary headache in adult ED patients and their in situ efficacy, based on literature data, the type of medications studied in randomized clinical trials for the management of adult ED patients, and the recommendations found in the guidelines for symptomatic treatment of migraine. We also report on the experience of the Parma University Hospital ED in the year 2007 for the management of adult patients diagnosed with primary headache. Finally, we propose an algorithm for primary headache management in ED patients, which is based on the literature data and clinical experience, and is suitable for application in Italy.
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31
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Bagdy G, Riba P, Kecskeméti V, Chase D, Juhász G. Headache-type adverse effects of NO donors: vasodilation and beyond. Br J Pharmacol 2010; 160:20-35. [PMID: 20331608 DOI: 10.1111/j.1476-5381.2010.00643.x] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
Although nitrate therapy, used in the treatment of cardiovascular disorders, is frequently associated with side-effects, mainly headaches, the summaries of product characteristics of nitrate-containing medicines do not report detailed description of headaches and even do not highlight the possibility of nitrate-induced migraine. Two different types of nitrate-induced headaches have been described: (i) immediate headaches that develop within the first hour of the application, are mild or medium severity without characteristic symptoms for migraine, and ease spontaneously; and (ii) delayed, moderate or severe migraine-type headaches (occurring mainly in subjects with personal or family history of migraine), that develop 3-6 h after the intake of nitrates, with debilitating, long-lasting symptoms including nausea, vomiting, photo- and/or phono-phobia. These two types of headaches are remarkably different, not only in their timing and symptoms, but also in the persons who are at risk. Recent studies provide evidence that the two headache types are caused by different mechanisms: immediate headaches are connected to vasodilation caused by nitric oxide (NO) release, while migraines are triggered by other actions such as the release of calcitonin gene-related peptide or glutamate, or changes in ion channel function mediated by cyclic guanosine monophosphate or S-nitrosylation. Migraines usually need anti-attack medication, such as triptans, but these drugs are contraindicated in most medical conditions that are treated using nitrates. In conclusion, these data recommend the correction of summaries of nitrate product characteristics, and also suggest a need to develop new types of anti-migraine drugs, effective in migraine attacks, that could be used in patients with risk for angina pectoris.
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Affiliation(s)
- G Bagdy
- Department of Pharmacodynamics, Faculty of Pharmacy, Semmelweis University, Budapest, Hungary.
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Abstract
Headache is the fifth most common primary complaint of patients presenting to an emergency department (ED) in the United States. The emergency physician (EP) plays a unique role in the management of these patients, one that differs from that of the primary care physician, the neurologist, and other specialists. Diagnostic nomenclature used in the ED is necessarily less specific, as care is more appropriately focused on the relief of symptoms and the identification of life-threatening causes. By seeking a limited number of specific critical features on history and physical examination, the EP can minimize the risk of overlooking one of these dangerous causes of headache. When certain features are present, empirical therapies and diagnostic testing should be initiated in the ED. The most frequently encountered pitfalls in the management of patients with headache in emergency medicine practice, and those with the greatest likelihood to adversely affect patient outcomes, are discussed.
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Dermitzakis EV, Georgiadis G, Rudolf J, Nikiforidou D, Kyriakidis P, Gravas I, Bouziani C, Tsiptsios I. Headache patients in the emergency department of a Greek tertiary care hospital. J Headache Pain 2009; 11:123-8. [PMID: 19997955 PMCID: PMC3452293 DOI: 10.1007/s10194-009-0178-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2009] [Accepted: 11/21/2009] [Indexed: 12/02/2022] Open
Abstract
The aim of this study was to record the demographic and epidemiological data on adult patients with headache who attend the emergency department (ED) and the diagnoses that made by the neurologists in the ED of a tertiary care hospital in metropolitan Thessaloniki (Greece). In an open prospective study, demographic and epidemiological data were collected on all patients who reported headache (as chief complaint or not) and presented to the ED of Papageorgiou Hospital between August 2007 and July 2008. Headache patients accounted for 1.3% of all ED patients and for 15.5% of patients primarily referred to the ED neurologist. Tension type headache was the most frequent diagnosis, followed by secondary headaches and migraine. The large number of patients without final ED diagnosis and ward admission for further evaluation sheds a light on the immense workload of Greek ED physicians. Furthermore, we found evidence for the misuse of Emergency Medical Services by chronic headache patients. These findings indicate shortcomings in the pre-hospital (primary care) management of headache patients in the Greek National Health System to an extent unreported so far.
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Affiliation(s)
- Emmanouil V Dermitzakis
- Department of Neurology, Papageorgiou General Hospital, Ring Road of Nea Efkarpia, Thessaloniki, Greece.
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Mostardini C, d'Agostino VC, Dugoni DE, Cerbo R. A Possible Role of ID-Migraine™ in the Emergency Department: Study of an Emergency Department Out-Patient Population. Cephalalgia 2009; 29:1326-30. [DOI: 10.1111/j.1468-2982.2009.01889.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Headache symptoms account for 1-3% of admissions to an emergency department (ED). Most patients affected by a primary headache (PH) have migraine, although they are often misdiagnosed as ‘headache not otherwise specified’. We investigated the possibility of using ID-Migraine (ID-M) to improve migraine recognition in the ED setting. We planned a pilot study involving ED out-patients with a diagnosis of PH. Diagnoses of a blinded headache expert were subsequently matched with the ID-M results. We tested ID-M on 230 patients (199 PH, 31 secondary headaches). Considering only PH, ID-M exhibited a sensitivity of 0.94 and specificity of 0.83 with a positive predictive value (PPV) of 0.99. The ID-M is a simple migraine screener with high sensitivity, high specificity and high PPV, even in an ED-derived population. Methodical use of this tool in an ED setting may, once a secondary headache has been excluded, lead to rapid diagnosis of migraine.
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Affiliation(s)
- C Mostardini
- Emergency Department Headache Centre, ‘Enzo Borzomati’ Pain Centre, Emergency Department, Azienda Policlinico Umberto I, ‘Sapienza’ University, Rome, Italy
| | - VC d'Agostino
- Emergency Department Headache Centre, ‘Enzo Borzomati’ Pain Centre, Emergency Department, Azienda Policlinico Umberto I, ‘Sapienza’ University, Rome, Italy
| | - DE Dugoni
- Emergency Department Headache Centre, ‘Enzo Borzomati’ Pain Centre, Emergency Department, Azienda Policlinico Umberto I, ‘Sapienza’ University, Rome, Italy
| | - R Cerbo
- Emergency Department Headache Centre, ‘Enzo Borzomati’ Pain Centre, Emergency Department, Azienda Policlinico Umberto I, ‘Sapienza’ University, Rome, Italy
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Martelletti P, Farinelli I, Steiner TJ. Acute migraine in the Emergency Department: extending European principles of management. Intern Emerg Med 2008; 3 Suppl 1:S17-24. [PMID: 18785015 DOI: 10.1007/s11739-008-0188-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
The World Health Organization (WHO) placed migraine 19th among all causes of disability (12th in women) measured in years of healthy life lost to disability (YLD). The importance of headache disorders, particularly of the primary forms, is established by their distribution worldwide, their duration (the majority being life-long conditions) and their imposition of both disability and life-style restrictions among large numbers of people. For these reasons, headache disorders should represent a public-health priority. In the Emergency Department (ED), as elsewhere, migraine is often under-diagnosed-and under-treated when it is diagnosed. The result is likely to be failure of treatment. Particular attention to diagnosis is needed in ED patients with acute headache, since there is a higher probability of secondary headache due to underlying pathologies. According to European principles of management, acute migraine treatment generally is stepwise. Of the two main steps, the first relies on symptomatic medication, preferably NSAIDs with or without antiemetics. The second step uses specific therapies, usually triptans. Modifications to routine practice are appropriate in the ED. Parenteral administration of symptomatic therapies is a preferred first choice, whilst immediate resort to triptans may be appropriate, and achieve better outcomes, in patients with severe headache and diagnostic confirmation of migraine.
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Affiliation(s)
- Paolo Martelletti
- Department of Medical Sciences, Internal Medicine, Regional Referral Headache Centre, 2nd School of Medicine, Sapienza University of Rome, Sant'Andrea Hospital, Via di Grottarossa 1035, 00189 Rome, Italy.
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