Treatment of Primary Headache in the Emergency Department

Harvey J. Blumenthal, MD; Michael A. Weisz, MD, FACP; Karen M. Kelly; Renae L. Mayer, MD; Jeffrey Blonsky, MS4

Headache. 2003;43(10) 

In This Article

Abstract and Case History

Background: Each year many patients present to an emergency department for treatment of acute primary headache. We investigated the diagnosis and clinical outcome of patients treated for primary headache in the emergency department.
Methods: Patients treated for acute primary headache in the emergency department completed a questionnaire related to their headache symptoms, response to treatment, and ability to return to normal function. These responses were compared to the treating physicians' observations of the patient's condition at the time of discharge from the emergency department.
Results: Based on the questionnaire, 95% of the 57 respondents met International Headache Society diagnostic criteria for migraine. Emergency department physicians, however, diagnosed only 32% of the respondents with migraine, while 59% were diagnosed as having "cephalgia" or "headache NOS" (not otherwise specified). All patients previously had taken nonprescription medication, and 49% had never taken a triptan. In the emergency department, only 7% of the patients received a drug "specific" for migraine (ie, a triptan or dihydroergotamine). Sixty-five percent of the patients were treated with a "migraine cocktail" comprised of a variable mixture of a nonsteroidal anti-inflammatory agent, a dopamine antagonist, and/or an antihistamine; 24% were treated with opioids. All 57 patients reported that after discharge they had to rest or sleep and were unable to return to normal function. Sixty percent of patients still had headache 24 hours after discharge from the emergency department.
Conclusion: The overwhelming majority of patients who present to an emergency department with acute primary headache have migraine, but the majority of patients receive a less specific diagnosis and a treatment that is correspondingly nonspecific.

A 34-year-old woman with migraine without aura since a teenager was treated in an emergency department (ED). She subsequently consulted the senior author (H.J.B.), and reported she had been treated with a "migraine cocktail." Review of her chart from the ED indicated that the cocktail consisted of ketorolac 30 mg, metoclopramide 10 mg, and diphenhydramine 25 mg; and the notes also indicated that the "HA [headache] completely resolved." The patient, however, reported this treatment was unsuccessful. She explained that initially the nausea ceased, the headache improved, and she felt much better, but as her husband drove her home the headache returned and within an hour of treatment, the headache was pounding as severely as before.

Introduction. Each year many patients present to an ED for treatment of primary headache (migraine, tension-type, cephalgia, or headache NOS [not otherwise specified]). Upon reviewing the literature regarding clinical outcomes of ED treatment of patients with severe acute migraine, we found that reported outcomes are limited to the ED encounter, but a more meaningful assessment must consider if response is sustained over 24 hours. The dissonance in treatment preferences and experience of ED physicians and those who specialize in headache management prompted this study.[1,2] We hypothesized that ED physicians overestimate the effectiveness of their treatment of primary headaches; specifically, treatment success after the patient has left the ED. The objectives of this study were to define ED physicians' diagnostic assessment of primary headache, to determine ED physicians' treatment preferences for primary headache, and to assess patient response to headache treatment, both in the ED and for 24 hours posttreatment.


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