A Randomized Controlled Trial of a Comprehensive Migraine Intervention Prior to Discharge From an Emergency Department

Authors

  • Benjamin W. Friedman MD, MS,

    1. From the Department of Emergency Medicine, Albert Einstein College of Medicine (BWF, JN, VA, CMC, DE, PEB, EJG), Bronx, NY; and the Pharmacy Department (CS) and the Department of Neurology and Montefiore Headache Center (SS, RBL), Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY.
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  • Clemencia Solorzano DrPh,

    1. From the Department of Emergency Medicine, Albert Einstein College of Medicine (BWF, JN, VA, CMC, DE, PEB, EJG), Bronx, NY; and the Pharmacy Department (CS) and the Department of Neurology and Montefiore Headache Center (SS, RBL), Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY.
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  • Jennifer Norton DO,

    1. From the Department of Emergency Medicine, Albert Einstein College of Medicine (BWF, JN, VA, CMC, DE, PEB, EJG), Bronx, NY; and the Pharmacy Department (CS) and the Department of Neurology and Montefiore Headache Center (SS, RBL), Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY.
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  • Victoria Adewumni MD,

    1. From the Department of Emergency Medicine, Albert Einstein College of Medicine (BWF, JN, VA, CMC, DE, PEB, EJG), Bronx, NY; and the Pharmacy Department (CS) and the Department of Neurology and Montefiore Headache Center (SS, RBL), Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY.
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  • Caron M. Campbell MD,

    1. From the Department of Emergency Medicine, Albert Einstein College of Medicine (BWF, JN, VA, CMC, DE, PEB, EJG), Bronx, NY; and the Pharmacy Department (CS) and the Department of Neurology and Montefiore Headache Center (SS, RBL), Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY.
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  • David Esses MD,

    1. From the Department of Emergency Medicine, Albert Einstein College of Medicine (BWF, JN, VA, CMC, DE, PEB, EJG), Bronx, NY; and the Pharmacy Department (CS) and the Department of Neurology and Montefiore Headache Center (SS, RBL), Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY.
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  • Polly E. Bijur PhD,

    1. From the Department of Emergency Medicine, Albert Einstein College of Medicine (BWF, JN, VA, CMC, DE, PEB, EJG), Bronx, NY; and the Pharmacy Department (CS) and the Department of Neurology and Montefiore Headache Center (SS, RBL), Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY.
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  • Seymour Solomon MD,

    1. From the Department of Emergency Medicine, Albert Einstein College of Medicine (BWF, JN, VA, CMC, DE, PEB, EJG), Bronx, NY; and the Pharmacy Department (CS) and the Department of Neurology and Montefiore Headache Center (SS, RBL), Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY.
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  • Richard B. Lipton MD,

    1. From the Department of Emergency Medicine, Albert Einstein College of Medicine (BWF, JN, VA, CMC, DE, PEB, EJG), Bronx, NY; and the Pharmacy Department (CS) and the Department of Neurology and Montefiore Headache Center (SS, RBL), Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY.
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  • E. John Gallagher MD

    1. From the Department of Emergency Medicine, Albert Einstein College of Medicine (BWF, JN, VA, CMC, DE, PEB, EJG), Bronx, NY; and the Pharmacy Department (CS) and the Department of Neurology and Montefiore Headache Center (SS, RBL), Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY.
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  • Some of this research was conducted with Dr. Friedman’s K23 Career Develoment Award from the National Institute of Neurological Disorders and Stroke 1K23NS051409.

  • The authors have no relevant financial information or potential conflicts of interest to disclose.

  • Supervising Editor: Steven B. Bird, MD.

Address for correspondence and reprints: Benjamin W. Friedman, MD, MS; e-mail: befriedm@montefiore.org.

Abstract

ACADEMIC EMERGENCY MEDICINE 2012; 19:1151–1157 © 2012 by the Society for Academic Emergency Medicine

Abstract

Objectives:  Patients who use an emergency department (ED) for acute migraine headaches have higher migraine disability scores, lower socioeconomic status, and are unlikely to have used a migraine-specific medication prior to presentation to the ED. The objective was to determine if a comprehensive migraine intervention, delivered just prior to ED discharge, could improve migraine impact scores 1 month after the ED visit.

Methods:  This was a randomized controlled trial of a comprehensive migraine intervention versus typical care among patients who presented to an ED for management of acute migraine. At the time of discharge, for patients randomized to comprehensive care, the research team reinforced their diagnosis, shared a migraine education presentation from the National Library of Medicine, provided them with six tablets of sumatriptan 100 mg and 14 tablets of naproxen 500 mg, and if they wished, provided them with an expedited free appointment to the institution’s headache clinic. Patients randomized to typical care received the care their attending emergency physicians (EPs) felt was appropriate. The primary outcome was a between-group comparison of the Headache Impact Test (HIT-6) score, a validated headache assessment instrument, 1 month after ED discharge. Secondary outcomes included an assessment of satisfaction with headache care and use of migraine-specific medication within that 1-month period.

Results:  Over a 19-month period, 50 migraine patients were enrolled. One-month follow-up was successfully obtained in 92% of patients. Baseline characteristics were comparable. One-month HIT-6 scores in the two groups were nearly identical (59 vs. 56, 95% confidence interval [CI] for difference of 3 = −5 to 11), as was dissatisfaction with overall headache care (17% vs. 18%, 95% CI for difference of 1% = −22% to 24%). Patients randomized to the comprehensive intervention were more likely to be using triptans or migraine-specific therapy (43% vs. 0%, 95% CI for difference of 43% = 20 to 63%) 1 month later.

Conclusions:  A comprehensive migraine intervention, when compared to typical care, did not improve HIT-6 scores (a validated measure of the effect of migraine on one’s daily life) 1 month after ED discharge. Future work is needed to define a migraine intervention that is practical and useful in an ED, where many underserved patients, of necessity, present for care.

Abstract

Resumen

Objetivos:  Los pacientes que acuden al servicio de urgencias (SU) por cefelea debida a una migraña aguda tienen mayores puntuaciones de discapacidad por la migraña, menor nivel socioeconómico y menor probabilidad de haber tomado un fármaco específico para la migraña previamente a la atención en el SU. El objetivo fue determinar si una intervención global para la migraña, realizada previamente al alta del SU, podía mejorar las puntuaciones de impacto de la migraña al mes tras la visita al SU.

Método:  Ensayo clínico controlado y con asignación aleatoria de una intervención global para la migraña versus una atención estándar en los pacientes que acudieron a un SU para el manejo de un episodio agudo de migraña. En el momento del alta, para los pacientes que fueron asignados a atención global, el protocolo del estudio reforzó su diagnóstico, compartió una presentación formativa sobre la migraña de la National Library of Medicine, se les suministró seis comprimidos de sumatriptan de 100mg y 14 comprimidos de naproxeno de 500mg y, si lo deseaban, se les concertó una cita gratuita con la unidad de cefaleas de la institución. Los pacientes que fueron asignados a una atención estándar recibieron la atención considerada apropiada por los urgenciólogos. El resultado principal fue la comparación entre grupos de la puntuación del Headache Impact Test (HIT-6), un instrumento validado de valoración de la cefalea, al mes del alta del SU. Los resultados secundarios incluyeron una valoración de la satisfacción de la atención por la cefalea y la frecuencia de uso de medicación específica para la migraña durante el periodo de un mes.

Resultados:  En un periodo de 19 meses, se incluyó 50 a pacientes con migraña. El seguimiento de un mes se obtuvo en el 92% de los pacientes. Las características basales fueron comparables. Las puntuaciones al mes del HIT-6 en los dos grupos fue casi idéntica (59 vs. 56, IC 95% para la diferencia = −5 a 11), así como la insatisfacción con la atención de la cefalea (17% vs. 18%, IC 95% para la diferencia = −22% a 24%). Los pacientes que fueron asignados a una intervención global tuvieron más probabilidad de tomar triptanes o terapia específica de la migraña (43% vs. 0%; IC 95% para la diferencia = 20 a 63%) durante el mes siguiente.

Conclusiones:  Una intervención global para la migraña, cuando se comparó con la atención estándar, no mejoró las puntuaciones del HIT-6 (una medida validada del efecto de la migraña en un día de la vida diaria) un mes tras el alta del SU. Futuros trabajos son necesarios para definir una intervención para la migraña que sea práctica y útil en un SU, donde muchos pacientes subatendidos acuden por necesidad para recibir atención.

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