Optimal management strategies for primary headache in the emergency department

DOI: https://doi.org/10.1007/s43678-021-00173-0

Abstract-Summary We sought to evaluate the factors associated with better outcomes for emergency department (ED) patients treated for primary headache.

The primary outcome was the need for second round medications, defined as medications received> 1 h after the initial physician-ordered medications were administered.

We performed multivariate logistic regression analysis to determine treatment

factors associated with need for second round medications.

Dopamine antagonists (OR 0.3 [95% CI 0.1–0.5]) and non-steroidal anti-inflam- matory drugs (NSAIDs) (OR 0.5 [95% CI 0.3–0.8]) ordered with initial medica- tions were associated with reduced need for second round medications.

Intravenous fluid boluses ≥ 500 ml (OR 2.8 [95% CI: 1.5–5.2]) and non-dopa- mine antagonist antiemetics (OR 2.2 [95% CI 1.2–4.2]) were associated with increased need.

We determined that use of dopamine antagonists and NSAIDs were associated with a reduced need for second round medications in ED primary headache patients.

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Non-dopamine antagonist antiemetic medications and intravenous fluids were

associated with a significantly increased need for second round medications.

Extended: We sought to determine which classes of medications and specific interventions were administered and what investigations were conducted for patients with primary headaches, with the primary objective of identifying management pat- terns associated with more effective and rapid resolution of symptoms for patients with primary headache in the ED.

The primary outcome for our study was the need for a second round of

medications.

Introduction Primary headaches account for 1–3% of all emergency department (ED) visits [254, 395, 396] and are one of the most frequent reasons for presentation to the ED.

The most common ED primary headache diagnoses are migraines (42–60%) and

headache not-otherwise- specified (25–42%) [141, 359, 396].

We aimed to describe the primary headache population presenting to a tertiary care ED, as well as the practice patterns of ED physicians in treating primary headaches.

We sought to determine which classes of medications and specific interventions were administered and what investigations were conducted for patients with pri- mary headaches, with the primary objective of identifying management patterns associated with more effective and rapid resolution of symptoms for patients with primary headache in the ED.

Methods This study was a health records review of consecutive adult patients who presented to the Ottawa Hospital EDs and were discharged with a diagnosis of primary head- ache over a 3-month period in 2018.

Eligible patients were identified searching the Ottawa Data Warehouse for ED patients ≥18 years old with ICD-10 discharge diagnoses of a primary headache.

As we aimed to evaluate treatment strategies for primary headache patients that led to discharge from the ED, we excluded patients who left without being seen by a physician, were transferred from another center for computed tomography (CT) imaging or assessment directly by a specialist, were admitted, were treated mainly for a condition other than primary headache, or had a principal diagnosis other than primary headache.

To ensure only primary headaches were included, all patients had their subse- quent ED visits over a minimum 10-month period (up until the time of chart review) audited for secondary headache diagnoses.

Results Patients who required second round medications were more likely to have received opioids (19.0% vs 6.4%, p < 0.001), antiemetics (23.0 vs. 7.3%, p < 0.001), and acetaminophen (43.0 vs. 32.7%, p = 0.01) compared to those that were successfully treated with the first round of medications.

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Patients who required second round medications were also more likely to have

had ED investigations (64.0 vs. 50.8%, p = 0.02) compared to those who did not.

For the secondary outcome, patients who had shorter lengths of stay were younger (mean age 40.1 vs 48.1, p < 0.001) and more likely to receive an NSAID in the first round of medications (72.3 vs. 62.0%, p = 0.02).

Discussion We found that ED primary headache patients administered NSAIDs or dopamine antagonists as initial treatments had significantly reduced need for subsequent medications.

Treatment with first round non-dopamine antagonist antiemetics was associated with significantly higher need for subsequent medications and with longer lengths of stay, highlighting the relative ineffectiveness of these medications in treating primary headache compared to dopamine antagonists.

There is little evidence to support the use of either ondansetron or dimenhydri- nate for primary headache, and the ineffectiveness of these medications as first line treatments is reflected in our study.

A potential future study could involve administering patients a combination of effective headache medications at triage and evaluating the impact of this strategy on lengths of stay and the need for subsequent medications to be ordered by an MD. This study suggests that for the optimal management of primary headaches in the ED, use of NSAIDs and dopamine antagonists may be associated with higher rates of initial treatment success.

Acknowledgement A machine generated summary based on the work of Wells, Simon; Stiell, Ian G.; Vishnyakova, Evgeniya; Lun, Ronda; Nemnom, Marie-Joe; Perry, Jeffrey J. 2021 in Canadian Journal of Emergency Medicine.

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