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 anti-headache effects, were used 6 times more commonly as adjuncts than the dopamine antagonists that have established anti-headache 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-hydroxytrypamine(1) [5-HT(1)] receptor agonists) are supported by strong evidence. However, parenterally treated patients with migraines received opioids as their only anti-headache medication more commonly than they received any of the aforementioned non-opioids 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.