Treatment patterns of isolated benign headache in US emergency departments

Abstract

Study Objective: I sought to describe and analyze the treatment of a large representative sample of adult US emergency department patients with isolated primary headache. Methods: Information on adult patients with an isolated diagnosis of migraine headache or unspecified headache was extracted from the 100.4 million ED visits represented by the 1998 National Hospital Ambulatory Medical Care Survey. Demographic and clinical information are presented with descriptive statistics. The treatment of migraine headache was assessed in light of Canadian and US practice parameters. Results: The migraine headache and unspecified headache cohorts included 811,419 and 604,977 participants, respectively. The majority of patients were young, white, and female. Patients received a mean of 1.8 medications from a pharmacopoeia of 36 drugs. Most patients (84.8%) given a diagnosis of migraine headache received a parenteral agent. The most commonly used medications were meperidine (30.0%), ketorolac (21.4%), and prochlorperazine (16.7%). Adjunct antiemetics were commonly administered with parenteral opioids (89.8%). Promethazine and hydroxyzine, antiemetics without antiheadache effects, were used 6 times more commonly as adjuncts than the dopamine antagonists that have established antiheadache effects (ie, prochlorperazine, metoclopramide, droperidol; 78.0% versus 11.8%). The US and Canadian recommendations for the use of nonopioid abortive medications (dopamine-antagonist antiemetics, dihydroergotamine, and 5-hydroxytrypamine₁ [5-HT₁] receptor agonists) are supported by strong evidence. However, parenterally treated patients with migraines received opioids as their only antiheadache medication more commonly than they received any of the aforementioned nonopioids in their regimen (45.7% versus 26.0%). Of all the opioid recipients, most (77%) did not receive any nonopioid abortive headache medication. Meperidine was the most commonly administered opioid (70%). Conclusion: Polypharmacy and a broad pharmacopoeia characterize the US ED treatment of isolated benign headache. Opioid use, particularly meperidine, exceeds that of recommended nonopioid abortive migraine medications. [Vinson DR. Treatment patterns of isolated benign headache in US emergency departments. Ann Emerg Med. March 2002;39:215-222.]

Introduction

Headache is a common condition in the United States for which emergency medical attention is frequently sought.1, 2 At the physician's disposal is an array of pharmacotherapeutic options. For mild-to-moderate headaches not associated with vomiting, a variety of oral agents and a large number of combinations are available. For moderate-to-severe headaches and those associated with vomiting, several categories of parenteral medications are in use, including oxygen, saline solution, nonsteroidal anti-inflammatory drugs, dopamine-antagonist antiemetics, ergotamines, 5-hydroxytrypamine₁ (5-HT₁) receptor agonists, mixed opioid agonist-antagonists, and opioid agonists. The efficacies, hazards, and costs of these respective therapies have been carefully reviewed.3, 6

For the management of acute migraine headache, guidelines exist that both rank the level of evidence supporting the use of each medication and recommend sensible treatment strategies.7, 8 There is, however, little specific information available regarding current treatment patterns in the United States. The number and types of medications used in emergency medicine for the relief of primary headache disorders have not been examined. Thus, this study was undertaken to describe the treatment of emergency department patients given a diagnosis of benign headache by using a US government national database.