An Algorithm for Opioid and Barbiturate Reduction in the Acute Management of Headache in the Emergency Department

Abstract

A quality improvement pilot study aimed at treating headache in an Emergency Department setting was successfully implemented in a regional Cleveland Clinic Hospital. Our results demonstrated significant decrease in acute treatment with opioids or barbiturates and a decrease in prescriptions written for opioids or barbiturates on discharge. This study is limited by small sample size. More data are needed to determine the reason for 1) increased consultation and subsequent admission after algorithm implementation and 2) decreased scheduled follow-up appointments at one-year post algorithm.

Abstracts and Citations

“…A seemingly not related group from Australia has proposed a randomized double-blind placebo controlled study on the same topic. 1 As an observation this is interesting, but this is a terrible study. WMC outlines 2 concerns, small sample size (15 patients treated with sumatriptan vs 45 controls) and heterogeneity of diagnosis provoking the surgery.…”

“…Prazosin was looked to as a possible treatment for PTSD, with some favorable small studies showing improvement in sleep and PTSD symptoms. 1,2 However, a larger article published in the New England Journal of Medicine and a subsequent meta-analysis article concluded no benefit. 3,4 Although these more recent studies were not positive, there may be some further exploration to be had for those with chronic headache and associated symptoms of adrenergic hyperactivity.…”

“…More than a decade ago this receptor was proposed to be potentially responsible for elements of peripheral activation and central sensitization in migraine. 1 Activation of TRPV1 has been shown to promote release of CGRP from trigeminal nerve terminals resulting in neurogenic inflammation within the meninges. 2 Phenylephrine at high concentrations is routinely used as a mydriatic agent and for the treatment of nasal congestion, and occasional patients report burning from the medications -hence the hypothesis that stimulation of TRPV1 might be involved.…”

“…There have been other papers identifying benefits of sumatriptan in an assortment of non-migraine headache disorders, so even if the sumatriptan-treated patients did not have migraine, response of "non-migraine" headache to sumatriptan would be nothing new. [1][2][3] To tie it to our prior abstract, perhaps the mechanism of action for non-migraine headache improvement includes action at the TRPV1 channel? 4 Methods: Participants are a random sample of recently deployed soldiers from the Warrior Strong cohort, consisting of soldiers with (n = 557) and without (n = 1030) a history of a recent mild traumatic brain injury (mTBI; concussion).…”

ACEP Guidelines on Acute Nontraumatic Headache Diagnosis and Management in the Emergency Department, Commentary on Behalf of the Refractory, Inpatient, Emergency Care Section of the American Headache Society

“…We would like to highlight protocols for headache management which may help to reduce the use of opioids for the acute treatment of primary headaches in the ED setting. Zubair et al discuss implementing an algorithm for managing headaches in the ED . This is one example of an approach to supporting care of patients with migraine in the ED while reducing recidivism.…”