Headache Evaluation and Treatment by Primary Care Physicians in an Emergency Department in the Era of Triptans
Morris Maizels, MD
Arch Intern Med. 2001;161:1969-1973.
Background Despite advances in treatment, patients with migraine have been underdiagnosed
and undertreated.
Methods Documentation of visits by patients with headache to an urgent care
department staffed by primary care physicians was reviewed. Patients were
also sent a brief headache screen, and those who replied were interviewed
by telephone. "Repeaters" (patients who made 3 or more visits in 6 months)
were excluded from chart review.
Results Over 6 months, 518 patients made 1004 visits to the emergency department
for primary headache complaints: 464 patients (90%) made 1 or 2 visits (total
visits, 502). A review of 174 charts documenting a diagnosis of migraine found
that (1) the need for prophylaxis was determined in only 40 (31%) of the patients
who were not already undergoing prophylaxis and (2) treatment in the emergency
department was migraine specific in 46 patients (26%) or otherwise appropriate
in 45 (25%). A review of 90 charts documenting nonmigraine diagnoses found
that 30 patients (33%) had adequate history documented to exclude migraine
as the diagnosis. Eighty-six patients (17%) were interviewed. An emergency
department diagnosis of migraine (n = 59) corresponded to a final diagnosis
of migraine with (n = 21) or without (n = 18) medication overuse or chronic
daily headache and/or transformed migraine with (n = 18) or without (n = 2)
medication overuse. Discharge diagnoses that were not migraine (n = 27) had
final diagnoses of migraine with (n = 9) or without (n = 9) medication overuse
or chronic daily headache/transformed migraine with (n = 7) or without (n
= 2) medication overuse.
Conclusions In this emergency department population, many patients with migraine,
chronic daily headache, or medication overuse are not accurately diagnosed.
The need for prophylaxis is not usually assessed. Treatment is migraine specific
in the minority of patients. Tension-type headache is rarely an accurate diagnosis
in this emergency department population.
From the Department of Family Practice, Kaiser Permanente, Woodland
Hills, Calif.
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