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Less Is Not More: Underutilization of Headache Medications in a University Hospital Emergency Department

Authors

  • Madhavi X. Gupta MD,

  • Stephen D. Silberstein MD,

  • William B. Young MD,

  • Mary Hopkins RN,

  • Bernard L. Lopez MD,

  • Gregory P. Samsa PhD


  • From the Jefferson Headache Center, Department of Neurology, Thomas Jefferson University, Philadelphia, PA, USA (Drs. Gupta, Silberstein, Young, and Hopkins); Department of Emergency Medicine, Jefferson Medical College, Philadelphia, PA, USA (Dr. Lopez); Department of Biostatistics and Bioinformatics, Duke University Medical Center, Durham, NC, USA (Dr. Samsa).

Address all correspondence to Dr. Madhavi Gupta, Center for Headache Management, Crozer Chester Medical Center, One Presidential Drive, Lewis House-First Floor, Upland, PA 19013, USA.

Abstract

Objective.—To gain knowledge of episodic headache patients who seek care at an urban university emergency department (ED), to evaluate the care they receive and to examine the impact of the ED on these headache patients.

Background.—In the United States, 1% of all ED visits are for the chief complaint of headache. The ED has a significant role in the identification and treatment of primary headache sufferers.

Methods.—Patients who presented to the ED with a chief complaint of headache were prospectively administered a patient survey, the PRIME-MD Patient Health Questionnaire, and MIDAS. Inclusion criteria: any patient 18 years or older with a nontraumatic headache of less than 1 month in duration. The patients included had episodic headache. Exclusion criteria: any patient with a history of a lumbar puncture or epidural procedure in the previous 7 days or those with chronic daily headache. Patients who met criteria were asked questions about headache type, health care utilization, satisfaction, co-morbid illnesses, and demographics. A neurologist independently reviewed the ED chart.

Results.—A total of 219 of 364 patients were eligible and consented. The median age was 34. Most (147, 67.1%) were women; 104 (47.5%) were diagnosed with migraine or probable migraine by chart review; 36% did not have enough information for a neurologist to code a diagnosis. Relatively few headache-specific medications were used 24 hours prior to ED arrival. Only 5% of patients were on headache-preventive medication. Patients commonly received neuroleptics (dopamine antagonists 98 [67.5%]) or opioids (93 [64.1%]) in the ED; however, 74 (33.8%) subjects received neither medication nor IV fluids. Upon leaving the ED, 21.8% were pain free and 89 (40.6%) patients were asked to follow-up with a physician. A total of 137 (62.6%) patients had no documented discharge medications. One person received a prescription for a preventive medication. Sixty-four percent of those who returned the diary reported that the headache returned within 24 hours of leaving the ED.

Conclusions.—Migraine ICHD-2 criteria are underused, and patients are undertreated in the ED. Many patients leave without a discharge diagnosis, outpatient medications, or instructions. ED physicians could help identify the migraineurs and channel them toward appropriate outpatient treatment.

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