Suboptimal migraine management rampant in the emergency department

Naveed Saleh, MD, MS, for MDLinx | October 19, 2018

Many headache specialists are unhappy with the care that their patients are administered in the emergency department (ED), according to a recent study published in Headache.

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High fees, long wait times, bright lights, noise, and suboptimal migraine care make the ED an inopportune setting for migraine treatment. And only approximately 20% of patients who present are pain-free at discharge.

“Our study sought to gain a better understanding of how providers with a special interest in ED/refractory headache approach and view the care of their patients when they require emergent or urgent care for a headache,” wrote the authors, led by Mia T. Minen, MD, MPH, assistant professor, Departments of Neurology and Population Health, and director, Headache Services, NYU Langone Headache Center, New York, NY.

Some patients with migraine cared for by a headache specialist go to the ED for treatment of acute headache. High fees, long wait times, bright lights, noise, and suboptimal migraine care make the ED an inopportune setting for such treatment. Further, only approximately 20% of patients who present to the ED for migraine are pain-free at discharge.

More than half of acute migraine attacks in the ED are treated with opioids—drugs that the American Headache Society (AHS) explicitly indicates should not be used as first-line treatment for this condition. In one recent study, single-dose prochlorperazine (a non-opioid) resulted in headache relief at twice the rate achieved with a single-dose of hydromorphone, a widely used opioid analgesic associated with longer hospital stays and prescription of additional drugs to control headache symptoms.

In this descriptive analysis, researchers surveyed 96 AHS Emergency Department/Refractory/Inpatient (EDRI) Section members (ie, headache specialists). Fifty responded (52%), of whom 80% practiced at an academic institution and 20% were in private practice.

Most  headache specialists reported prescribing their patients rescue treatment to deal with severe headache, and most used standard protocols for outpatients who did not respond to routine acute headache treatments.

Following a request for urgent care for headache by the patient, 54% of headache specialists reported bringing patients into the office some or most of the time, and 40% reported dispatching patients to the ED some or most of the time. Furthermore, a full 68% reported prescribing a new drug some or most of the time, and 52% noted providing telephone counseling some or most of the time.

Importantly, 62%—nearly two-thirds—of specialists were either inconsistently, often not, or not satisfied with the ED’s management of their headache patients.

However, only 20% of surveyed headache specialists reported discussing ED and urgent care with their patients, which indicated a barrier to communication.

The authors suggested that, based on their results, certain opportunities exist to decrease the need for ED visits in patients with acute headache. For instance, a substantial minority of physicians don’t give rescue medications to patients with headache despite the possible benefits. Additionally, more EDs could institute headache protocols.

“To reduce the high number of headache patients in the ED, education and intervention methods can be taught to patients, as well as step-wise elaboration of medications and treatment plans, when initial therapy does not work,” the authors wrote. “Better education and communication with respect to the ED is also essential to improved ED treatment of headache patients.”

The researchers conceded that their study had certain limitations. For instance, they only gathered responses from AHS members, and the hospitals of those surveyed may be more prone to having headache protocols in place, thus biasing results. Furthermore, because most of the specialists worked in academic settings, the results of the current study may not generalizable to private practice settings.

“A substantial number of headache specialists are dissatisfied with the care their patients receive in the ED,” concluded the researchers. “More standardized protocols for ED visits by patients with known headache disorders, and clear guidelines for communication between ED providers and treating physicians, along with better methods for follow-up following discharge from the ED, might appear to improve this issue.”

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