Examining Trends in Headache-Related ED Visits, Treatment

Between 2007 and 2018, opioid analgesic use substantially decreased among US headache-related emergency department (ED) visits, in compliance with evidence-based guideline recommendations for headache management, according to analysis findings published in the Journal of Clinical Medicine.

Severe and sudden headaches account for 3.5 million ED visits per year in the United States, with primary headache disorders (migraine, tension-type headache, and trigeminal autonomic cephalalgias) comprising the majority of these visits, authors explained.

These patients “often receive unnecessary neuroimaging or medications with low-quality evidence during ED visits due to the difficulty in differentiating primary headaches from secondary headaches, incomplete relevant medical histories, and a lack of consensus on the best treatment strategies in ED settings,” they added.

Furthermore, to avoid unnecessary radiation exposure and reduce health care costs, it is imperative for providers to be judicious and selective when determining whether to carry out neuroimaging.

To better understand acute headache treatment trends in an ED setting, researchers assessed patient and visit characteristics between 2007 and 2018 using National Hospital Ambulatory Medical Care Survey (NHAMCS) data.

The information is nationally representative of US hospital-based ambulatory care settings and is collected and distributed by the US National Center for Health Statistics. All patients included in the current analysis were at least 18 years old and had a primary ED discharge diagnosis of headache; data were aggregated into 3 time periods: 2007-2010, 2011-2014, and 2015-2018.

Of the 33 million headache-related ED visits within the window examined, one-third (32.9%) were due to migraines, whereas tension-type headaches and trigeminal autonomic cephalalgias represented 3.2% of visits. The remaining were unspecified.

“Most headache-related ED visits were from patients aged [younger than] 50 years (70.7%), female (72.9%), and White (70.3%). Nearly half of headache-related ED visits were from patients without any chronic diseases (46.3%),” authors wrote.

Additional analyses revealed:

• Opioid use decreased from 54.1% in 2007-2010 to 28.3% in 2015-2018 (P_trend < .001).
• There were statistically significant increasing trends in use of acetaminophen/nonsteroidal anti-inflammatory drugs (NSAIDs), diphenhydramine, and corticosteroids use (all P_trend < .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.
• ED visits with outpatient referral for follow-up increased slightly from 73.3% in 2007-2010 to 79.7% in 2015-2018 (P_trend = .02).
• Neuroimaging use remained unchanged over time (37.3% in 2015-2018 [P_trend = .91]).

In over half of the visits recorded, 3 or more medications were administered, and in 54.1% of patients, no medication was prescribed at the time of discharge.

With regard to migraine specifically, as compared with not otherwise specified (NOS) headaches, researchers found:

• Migraine-related visits had a greater use of ergot alkaloids/triptans (9.7% vs 1.9% in 2015–2018), antiemetics (80.3% vs 48.3%), diphenhydramine (47.5% vs 30.0%), and intravenous fluids (48.1% vs 37.9%).
• Acetaminophen/NSAID and corticosteroid use appeared to increase more rapidly among migraine-related visits.
• Neuroimaging use in NOS-headache–related visits was nearly twice that of migraine-related visits (44.3% vs 23.6% in 2015-2018).

Several guideline recommendations issued throughout the last decade call for the decreasing use of opioids when treating headaches. These recommendations came alongside increased efforts to mitigate the opioid crisis in the country throughout that same time.

Although many factors may contribute to a physician’s decision to conduct neuroimaging on patients with NOS headache, researchers noted “future studies are warranted to develop a valid and reliable quick screening tool to identify patients with a primary headache that can be easily applied in ED settings.”

A lack of patient follow-up data, information to differentiate primary from secondary headaches, and on sequence of medication use mark limitations to this analysis. Unmeasured confounders could have also impacted medication use trends over time.

Overall, “our study was the first to comprehensively examine medication and health service use for headache management in US EDs using nationally representative data,” the authors concluded.

“Future studies are warranted to identify strategies to promote evidence-based treatments for headaches (eg, sumatriptan and dexamethasone) and appropriate outpatient referrals for follow-up and to reduce unnecessary neuroimaging orders in EDs,” they said.

Reference

Yang S, Orlova Y, Lipe A, et al. 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. Published online March 3, 2022. doi:10.3390/jcm11051401