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Vol. 161 No. 16, September 10, 2001 |
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Original Investigation |
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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.
ABSTRACT
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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.
INTRODUCTION
ANNUALLY, more than 10% of the population experiences at least 1 migraine
headache.1 Migraine has a major economic impact2 and strongly affects an individual's quality of life.3 Despite significant disability, many patients with
migraine remain undiagnosed. In a population-based survey, only 41% of women
and 29% of men with migraine had ever had their migrane diagnosed by a physician.4 Of patients with migraine who do present to a physician,
only 45% to 51% receive a correct diagnosis.5
Patients with chronic daily headache (4%-5% of adults) and drug-rebound
headache (1.5% of adults) may have severe disability as well.6-7
Drug-rebound headache is a daily headache sustained by the daily intake of
analgesic agents or headache remedies. It is the most common reason for refractory
headache. Drug-rebound headache has been coined an unrecognized
epidemic.8
Although most (54%) migraineurs first consult their family physician
or internist, the next most common site for medical care is an emergency department
(ED), accounting for 16% of first presentations.9
Few articles have characterized the nature of care for patients with headache
in the ED. In one study of a health maintenance organization over a 4-month
period in 1991 and 1992, 152 patients made 323 ED visits for migraine: 36%
of the patients made repeat visits, averaging 4.2 visits for migraine in the
4-month period.10 Eighty-six percent of patients
were treated in the ED with narcotics; 6% were given a discharge prescription
for a migraine-specific compound (ergot or isometheptene compound); and 3%
were given a prescription for a migraine prophylaxis ( -blockers, tricyclic
agents, or calcium channel blockers).
The introduction of sumatriptan in 199111
revolutionized the treatment of acute migraine. Our study sought to evaluate
the nature of care of primary headache conditions in the ED in the "triptan
era."
PATIENTS AND METHODS
PATIENTS
Our medical group serves a large health maintenance organization with
about 3 million members. The local facility serves a population of 160 000.
The urgent care department (UCD) is situated next to the ED; patients presenting
with headache would be seen in the UCD between 7 AM and 10 PM daily and in
the ED after hours. Approximately 245 patients are seen in the UCD daily.
The UCD is staffed by 5 full-time UCD physicians and a mixture of approximately
20 per-diem physicians and 50 full-time primary care physicians. All physicians
are board certified or board eligible in internal medicine or family practice.
On a weekly basis, UCD notes were reviewed to identify patients who
were discharged with a primary headache disorder (migraine, tension-type headache,
or headache otherwise unspecified). Patients with associated febrile conditions
or medical conditions that were likely to explain the headache (eg, sinus
symptoms or uncontrolled hypertension) were excluded. Headaches due to recent
trauma were excluded. Patients who were evaluated for "worrisome" headaches
were also excluded. Emergency department (as opposed to UCD) notes were not
reviewed because patients visiting the ED more commonly presented with worrisome
headache syndromes.
Chart review was limited to patients with fewer than 3 visits to the
ED in 6 months (nonrepeaters). Charts of patients with 3 or more visits to
the ED in 6 months (repeaters) were not reviewed because these patients were
usually well known to the ED staff, usually presented with a request for narcotic
injection, and typically received little evaluation.
CHART REVIEW METHODS
For patients diagnosed as having migraine, we reviewed the charts if
there was documentation of migraine prophylaxis, and if not, documentation
of headache frequency. Medications considered to be migraine prophylaxis included
tricyclic antidepressant, any -blocker or calcium channel blocker, valproic
acid, or gabapentin. Serotonin-specific reuptake inhibitors and other antidepressants
were not considered migraine prophylactic agents. Appropriate reasons not
to take prophylaxis included documented headache frequency of less than twice
a month, documented lack of disability with headaches, failure with several
prophylactic agents, or being followed by a neurologist.
For patients diagnosed as having migraine, we also checked if the prescribed
treatment (both in the ED and at home) was migraine specific, and if not,
if there was a documented reason not to use migraine-specific therapy. Migraine-specific
treatment in the ED included any triptan or dihydroergotamine mesylate. Narcotics,
parenteral nonsteroidal drugs (ketorolac tromethamine), and antiemetic agents
were not considered migraine specific. Appropriate reasons for not using migraine-specific
therapy included allergy to triptans; previous documented failure with such
agents; unsuccessful use of triptan therapy for current headache episode;
and contraindication to triptans because of a history of coronary artery disease
or stroke, uncontrolled hypertension, or basilar or hemiplegic migraine. Relative
contraindications were the presence of any 2 cardiac risk factors, including
diabetes mellitus, hypertension, hyperlipidemia, smoking, age greater than
40 years for men or 50 years for women (or if no other risk factor was present, >50
years for men or >55 years for women). Migraine-specific treatment at home
included ergotamine products, Midrin (Carnrick Laboratories Inc, Cedar Knolls,
NJ), triptans, and dihydroergotamine. Butalbital products, nonsteroidal anti-inflammatory
agents, and analgesic agents were not considered migraine specific.
For patients diagnosed as having headache other than migraine, we determined
whether the history was adequate to exclude migraine based on criteria of
the International Headache Society12 (Table 1). For all patients, we checked
what physical examination was documented. Charts were reviewed for funduscopy
and neurologic examination. An adequate neurologic examination was defined
as any mention of cranial nerves and a motor response or deep tendon reflex
examination.
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Table 1. International Headache Society Criteria for Diagnosis of Migraine
Without Aura*
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After the first 3 months of chart review, protocol was revised to allow
further investigation, and all patients were mailed a brief headache survey.
Patients who returned the survey were contacted by telephone by a trained
interviewer to confirm a clinical diagnosis. If the diagnosis did not conform
to International Headache Society criteria12
for migraine, patients were diagnosed according to the revised criteria of
Silberstein et al,13 as having transformed
migraine (history of episodic migraine, now with daily headache); chronic
tension-type headache; and either of these with or without medication overuse
(use of analgesic agents or headache remedies >3 d/wk). The study design was
approved by the institutional review board. Informed consent was not required.
RESULTS
Over 6 months, 518 patients made 1004 visits to the ED for primary headache
complaints (Table 2): 426 patients
(82%) made a single visit; 38 (7%) made 2 visits; and 54 (10%) made 3 or more
visits (repeaters). Of all visits, 349 were to the UCD by nonrepeaters. From
these 349 visits, 264 charts were available for review: 174 documented a discharge
diagnosis of migraine, and 90 documented a nonmigraine headache diagnosis.
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Table 2. Distribution of Patients by Number of Visits to the Emergency
Department During a 6-Month Period*
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Eleven patients not previously identified as having migraine were diagnosed
by UCD physicians. All other diagnoses of migraine were in patients who had
identified themselves as having migraine. Overall, the need for prophylaxis
was determined in only 40 patients (31%) who were not already undergoing prophylaxis.
Two patients were started on prophylactic treatment. Evaluation of physical
examinations found documentation of funduscopic examination in 37 migraineurs
(27%) and an adequate neurologic examination in 7 (5%).
Table 3 summarizes the treatment
of patients discharged with a diagnosis of migraine. Treatment in the ED was
migraine specific for 46 patients (26%) or otherwise appropriate for 43 (25%).
Migraine-specific treatment in the ED was highly associated with a written
prescription of a migraine-specific therapy. For the patients who received
migraine-specific care in the UCD (n = 46), 25 (54%) received migraine-specific
prescriptions for home use, of which 20 were for triptans. Only 1 patient
in the group not given migraine-specific care in the UCD received a triptan
prescription.
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Table 3. Treatment of Patients With Urgent Care Discharge Diagnosis
of Migraine (n = 174)*
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The physician diagnoses of the 90 patients who were not diagnosed as
having migraine are summarized in the tabulation
below.
An adequate history to exclude migraine was documented in 30 (33%) records.
Funduscopic examination was documented in 33 (37%) and an adequate neurologic
examination in 8 (9%).
A brief headache survey was mailed to all 518 patients: 92 were returned,
of which 86 responders were available for interview. Table 4 compares the UCD diagnoses with the clinical diagnoses made
by a telephone interviewer. Tension-type headache without associated migraine
or medication overuse was confirmed in only 1 patient.
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Table 4. Urgent Care Diagnoses vs Diagnoses by Trained Telephone Interviewer*
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COMMENT
Previous studies of ED care for headache did not distinguish patients
with frequent ED visits for headache (labeled as migraine) from patients who
were infrequent users of ED resources. Our population sample of ED nonrepeaters
was selected because one would expect these patients to receive an adequate,
even if brief, evaluation in the ED. Furthermore, since the medical staff
is composed of family physicians and internists, the documented care may reflect
the care of patients with primary headache outside an ED setting.
Of the charts for patients not diagnosed as having migraine, only 30
(33%) had adequate information to exclude migraine. That this is not just
a documentation failure is confirmed by the patients who returned their headache
surveys: 24 (89%) of 27 patients not diagnosed as having migraine were found
to have either migraine (18 [67%]) or transformed migraine (6 [22%]), with
or without medication overuse. Many cases of chronic daily headache occur
in patients with a history of episodic migraine that has evolved into daily
headache, so-called transformed migraine.7 It seems, then, that many physicians are not familiar
with the diagnostic criteria for migraine published by the International Headache
Society12 (Table 1) or the importance of recognizing transformed migraine and
medication overuse. A simple mnemonic to aid in the diagnosis of migraine
has been suggested (Figure 1). 14
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Mnemonic criteria for migraine based on International Headache Society
criteria (Table 1).12
Diagnosis of migraine requires 2 of the first 4 criteria, and 1 of the second
2 criteria. Migraine is episodic and usually lasts 4 to 72 hours.
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More than half of the patients who were treated in the ED and were appropriate
candidates received migraine-specific therapy in the ED. This figure is higher
than it would be if the ED repeaters who were diagnosed as having migraine
were included in the database. Absolute and relative contraindications to
triptans, as well as the patient's previous experience with triptans, must
be considered when judging whether the care is appropriate. Migraine-specific
care in the ED is strongly associated with an appropriate prescription for
home care. All but 1 of the outpatient triptan prescriptions were given to
patients who received migraine-specific care in the ED.
Many patients who present to the ED with acute headache could benefit
from prophylaxis. Migraine, similar to asthma, is a chronic disease with acute
flares. Recognition of the need for prophylaxis is an important aspect of
emergency care. Guidelines for migraine prophylaxis have been suggested.15 A useful question may be, "Do your headaches trouble
you enough to take daily preventive medication?"
Chronic daily headache is important to recognize because it is most
appropriately treated with prophylaxis rather than with immediate medication.
Medication overuse or drug-rebound headache should be recognized because the
headache will not improve until symptomatic treatment is stopped and an appropriate
prophylaxis is administered. Failure to recognize drug-rebound headache is
an important reason for treatment failure.
There are no agreed-on standards for the evaluation of patients with
migraine in the ED. The approach of one headache expert is given in Table 5.16
Findings from history review and physical examination are used to exclude
worrisome causes of headache that may mimic migraine, and (juris)prudence
would suggest a minimal evaluation of all patients with migraine. Although
our UCD is staffed by primary care physicians, one cannot necessarily infer
that the same level of care would occur in a primary care setting. Patients
visit the ED for immediate relief rather than long-term management. However,
for some patients the ED visit may be their only interaction with the health
system for their headache disorder.
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Table 5. Sample Evaluation for a Patient With Migraine Before Relief
Medications Are Given*
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CONCLUSIONS
Our study of primary care physicians in an ED setting confirms previous
studies showing that migraine is underdiagnosed and undertreated. Evaluation
of these patients suggests that (1) most patients diagnosed as having migraine
in the ED have transformed migraine; (2) most patients given nonmigraine diagnoses
have migraine or transformed migraine; (3) medication overuse is common in
ED patients with headache; (4) most ED patients with headache are not undergoing
prophylaxis, even those who experience daily headache or consume analgesic
agents daily; and (5) tension-type headache without medication overuse is
rarely an accurate diagnosis in the ED. Physicians who work in urgent care
settings have an important opportunity to improve the care of patients with
primary headache disorders.
AUTHOR INFORMATION
Accepted for publication December 5, 2000.
This study was supported by an education grant from Merck & Co Inc,
West Point, Pa.
The author is indebted to Raoul Burchette, MA, MS, for statistical support.
An abstract of this article was presented at the 42nd Annual Scientific
Meeting of the American Headache Society, Montreal, Quebec, June 24, 2000.
Corresponding author and reprints: Morris Maizels, MD, Department
of Family Practice, Kaiser Permanente, 5601 De Soto Ave, Woodland Hills, CA
91365-4084 (e-mail: Morris.Maizels{at}kp.org).
From the Department of Family Practice, Kaiser Permanente, Woodland
Hills, Calif.
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