Adherence to guidelines of treatment of non-traumatic headache in the emergency department

DOI: https://doi.org/10.1007/s13760-020-01272-y

Abstract-Summary To evaluate therapies employed in patients presenting to the emergency department (ED) with a chief complaint of non- traumatic headache to check if guidelines are followed.

A 6-month retrospective analysis of the ED records of all the patients who referred to the ED of the University Hospital of Trieste for non-traumatic headache was performed.

One-hundred-ninety-three patients were treated in mono- (51.8%) or poly-ther- apy (48.2%), with NSAIDs (46.5%), benzodiazepines (13.4%), antiemetics (10.7%), analgesics (8.3%), opioids (1.6%), triptans (1.5%), and other drugs (17.7%).

NSAIDs, particularly ketorolac, are the class of drugs most often prescribed in

ED, independently of the discharge diagnosis.

In accordance with the current guidelines, NSAIDs monotherapy or in associa-

tion with antiemetics were the drugs most often prescribed in ED.

Special attention should be drawn also in ED to apply the International Classification of Headache Disorders criteria, which can lead to clarify the diagno- sis and receive the specific treatment.

Introduction Non-traumatic headache (NTH) is a common condition accounting for 0.6–4.5% of all emergency department (ED) visits [396, 403–406].

The management of patients with severe acute headache in ED represents a diag-

nostic and therapeutic challenge for ED physicians.

4.4 Emergency Department Management

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Primary headaches are often underestimated in ED, and even if specific guide- lines and recommendations related to the management of primary headache are available [407–411], they are rarely used in the ED setting.

In this situation, the treatment of primary headache is highly variable and strictly

dependent on the preferences and the experience of the ED physician [412].

Methods We performed an observational retrospective cohort survey of the ED medical records of all patients referring over a 6-month period (01/01/2017–30/06/2017) to the ED of the province of Trieste with NTH as chief complaint.

The analysis of the diagnostic and therapeutic procedures described in the ED medical records was performed by a neurologist experienced in headaches using the Hospital’s medical registration database.

Patients discharged with a nonspecific diagnosis were classified as Not Otherwise Specified (NOS) headache, independently from the diagnostic procedures adopted in the ED.

The patients admitted to the hospital ward were excluded from this analysis, because their length of stay in ED was very variable according to the severity of the underlying pathology and the different diagnostic and therapeutic procedures adopted.

For each patient, the demographic characteristics, the number of admissions in ED, the treatment, the time spent in ED, the final diagnosis at discharge were ana- lyzed using the ED data recording system.

Results One-hundred-ninety-three patients (56.5%) received treatment in the ED for a total of 262 administrations, the others (43.5%) did not receive any medication in ED, because head pain was considered not severe or receding at the moment of the visit. Other drugs (17.7%) were administered to the patients with secondary headaches

for the treatment of the cause of the pain.

Only four patients (1.5%) received a triptan in ED (sumatriptan 6 mg s. c.). Out of 56 patients with an ED diagnosis of migraine, 40 received a medication

and only 2 (3.5%) a triptan.

Only one out of three patients with cluster headache was treated with sumatrip-

tan 6 mg s.c.

Among treated patients, there were no differences in the length of stay of patients with primary headache (43, 32.1%), with secondary headache (34, 25.4%), and NOS headache (57, 42.5%).

Discussion High percentages of secondary and NOS headaches have already been reported in ED retrospective studies, while in the prospective studies, the prevalence of primary headaches is higher than the other two forms, indicating that most NOS headaches may consist of primary headaches [396, 405, 406].

Patients with tension-type headache rarely present to the Emergency Room, in

these cases, NSAIDs are the most effective treatment.

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4 Treatment

Patients with cluster headaches generally present in the ED when they have fre-

quent daily attacks.

It has already been reported that the ED doctors do not use frequently triptans to

treat migraine attacks (2–21%) and cluster headache (up to 53%) [406, 413].

We emphasize the importance of continuing to apply the guidelines for the treatment of headache in the emergency room and to use at least the first diagnostic level of the ICHD criteria also in the ED setting, which can lead to the proper treatment.

Acknowledgement A machine generated summary based on the work of Granato, Antonio; Morelli, Maria Elisa; Cominotto, Franco; D’Acunto, Laura; Manganotti, Paolo. 2020  in Acta Neurologica Belgica.

4.5

Pregnancy

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Migraine Treatment in Pregnancy and Lactation