Acute migraine management in the emergency department: experience from a large Spanish tertiary hospital

DOI: https://doi.org/10.1007/s11739-021-02698-9

Abstract-Summary To assess the characteristics of the management of patients with migraine who pres- ent to the emergency department (ED) with a migraine attack.

Retrospective, observational study analyzing demographic, clinical, diagnostic and therapeutic characteristics of patients with migraine diagnosis presenting to ED for a migraine attack between 2016 and 2019.

We reviewed the clinical records of 847 cases. 62.3% (528/847) had taken analgesics before visiting the ED [non-steroidal-anti-

inflammatory drugs (NSAIDs) (300/528; 56.9%) and triptans (261/528; 49.5%)].

Medication was administered in 77.2% cases (654/847). Triptans were administered in 7 cases (1.1%) and opioids in 84 (12.8%). At discharge, preventive treatment was prescribed or modified in 8.2% of cases

(69/839) and triptans were prescribed in 129 cases (15.3%).

The majority of migraine patients were not receiving the recommended acute migraine-specific medication, both in the outpatient and in the ED setting, being especially remarkable the rare use of triptans in the ED.

Extended: Medication was administered in the ED in 77.2% cases (654/847), the

intravenous (IV) route of administration was used in 73.7% cases (482/654).

The majority of prior studies about acute migraine management in the ED setting

were conducted in the USA, with limited research performed in Spain.

Introduction According to the data provided by the 2018 Spanish Migraine Atlas [398], visits to the emergency department (ED) were the most employed health resources by patients with migraine in Spain.

The majority of prior studies about acute migraine management in the ED setting

were conducted in the USA, with limited research performed in Spain.

We consider essential to gain knowledge of the management of patients with migraine presenting to the ED for acute migraine in our setting, where at this moment there is not any stablished protocol or educational project for ED staff, as a starting point to establish protocols to optimize the approach of patients with migraine.

The aim of our study is to assess the characteristics of patients with migraine who visited the ED for acute migraine and their diagnostic and therapeutic manage- ment in the ED.

Methods This is a retrospective chart review of patients with migraine who visited the ED of a tertiary hospital for a migraine attack between January 1, 2016 and December 31, 2019.

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Eligible patients were those older than 15 years with a previous diagnosis of

migraine and with the ED discharge diagnosis of ‘migraine’ (ICD9 346).

Exclusion criteria were (1) patients without previous migraine diagnosis who were diagnosed with migraine in the ED (2) patients with migraine diagnosis that visited the ED for other reason.

The following data about patients’ characteristics were collected: baseline demo- graphics, migraine type (according to the International Classification of Headache Disorders (ICHD)-3 criteria) [399], prior follow-up for migraine, migraine preven- tive treatment utilization, migraine attack duration prior to ED visit, visit to primary urgent care prior to ED and outpatient acute migraine treatment.

Results Among a total of 544,274 visits to the ED during the study period, 7348 patients visited the ED for headache and 1342 of these patients had a discharge diagnosis of migraine.

89 cases (10.5%) had visited their primary care provider (PCP) for the migraine

attack and 62.3% (528/847) had taken abortive medications prior to the ED visit.

In 69 cases (8.2% of patients discharged), prophylactic migraine treatment was started or modified at discharge, with amitriptyline being the most used medication (24/69; 34.8%).

20 patients (2.4%) revisited the ED within 24 h for a migraine attack and 18 patients (2.1%) within the following 48 h. Not significant differences were found in the treatment received in the ED between patients who revisited ED compared to patients discharged without ED re-admission.

Discussion We highlight different findings: The majority of patients who visited the ED with a migraine attack had episodic migraine as reported in previous studies [400, 401] and most patients were not followed-up for their migraine or were followed-up by their PCP.

These findings are indicative of a suboptimal acute treatment management in the outpatient setting and given that most patients were not followed-up by a neurolo- gist, additional education about abortive treatment options and, particularly, about migraine-specific medication may be given to PCP and to patients with migraine.

This could be explained because, in the management of patients with migraine, in our hospital neurologist are usually consulted when there are diagnostic doubts about the headache diagnosis or in patients who are refractory to the treatment administered in the ED.

Strengths and limitations Our study represents a large retrospective sample and provides a detailed descrip- tion of the profile of patients with migraine who visited the ED for a migraine attack as well as a current vision of their management in this setting.

Only patients with migraine diagnosis at discharge were included, which means that patients labeled with a wrong diagnosis (mostly tension type headache) were not included.

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Conclusions We found the majority of migraine patients were not receiving the recommended acute migraine-specific medication, both in the outpatient and in the ED setting, being especially remarkable the rare use of triptans in the ED.

We found an elevated use of urgent complementary tests in the ED, mainly blood

tests, which could be prevented.

Given this great variability on migraine management, we think that stablishing specific protocols about complementary tests, migraine treatment and post-dis- charge care and implementing educational projects about migraine are two essential measures that could potentially improve the management of patients with migraine in the ED and contribute to a better long-term outpatient care.

Acknowledgement A machine generated summary based on the work of Navarro-Pérez, María Pilar; Ballesta-Martínez, Sara; Rodríguez-Montolio, Joana; Bellosta-Diago, Elena; García-Noaín, José Alberto; Santos-Lasaosa, Sonia. 2021  in Internal and Emergency Medicine.

Lost diagnoses in not otherwise specified headache in Emergency Department