Optimal management strategies for primary headache in the emergency department

Abstract

Purpose: We sought to evaluate the factors associated with better outcomes for emergency department (ED) patients treated for primary headache. Methods: This was a health records review of consecutive patients over a 3-month period presenting to two tertiary EDs and discharged with a diagnosis of primary headache. The primary outcome was the need for second round medications, defined as medications received > 1 h after the initial physician-ordered medications were administered. We performed multivariate logistic regression analysis to determine treatment factors associated with need for second round medications. Results: We included 553 patients, mean age was 42.2 years and 72.9% were females. The most common diagnoses were headache not otherwise specified (48.8%) and migraine (43%). Ketorolac IV (62.2%) and metoclopramide IV (70.2%) were the most frequently administered medications. 18% of patients met the primary outcome. Dopamine antagonists (OR 0.3 [95% CI 0.1–0.5]) and non-steroidal anti-inflammatory drugs (NSAIDs) (OR 0.5 [95% CI 0.3–0.8]) ordered with initial medications were associated with reduced need for second round medications. Intravenous fluid boluses ≥ 500 ml (OR 2.8 [95% CI: 1.5–5.2]) and non-dopamine antagonist antiemetics (OR 2.2 [95% CI 1.2–4.2]) were associated with increased need. Opioid use approached statistical significance for receiving second round medication (p = 0.06). Conclusion: We determined that use of dopamine antagonists and NSAIDs were associated with a reduced need for second round medications in ED primary headache patients. Conversely, non-dopamine antagonist antiemetic medications and intravenous fluids were associated with a significantly increased need for second round medications. Careful choice of initial therapy may optimize management for these patients.