Recurrence of Primary Headache Disorders After Emergency Department Discharge: Frequency and Predictors of Poor Pain and Functional Outcomes

Friedman, Benjamin W.; Hochberg, Michael L.; Esses, David; Grosberg, Brian M.; Rothberg, Daniel; Bernstein, Benjamin; Bijur, Polly E.; Lipton, Richard B.; Gallagher, E. John

doi:10.1016/j.annemergmed.2008.01.334

Cited by 43 publications

(32 citation statements)

References 44 publications

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“…85 However, studies have shown that there is no association between sex and poor three-month pain outcomes among ED patients with low back pain or primary headache disorders. 86,87 In addition, research to date demonstrates important sex differences in related biological processes, supporting the potential importance of this research. 88–94 For example, studies have shown that hormonal variations related to the menstrual cycle affect both neural plasticity and immune system function.…”

Section: Resultsmentioning

confidence: 54%

Gender Differences in Acute and Chronic Pain in the Emergency Department: Results of the 2014Academic Emergency MedicineConsensus Conference Pain Section

et al. 2014

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Pain is a leading public health problem in the United States, with an annual economic burden of more than $630 billion, and is one of the most common reasons that individuals seek emergency department (ED) care. There is a paucity of data regarding sex differences in the assessment and treatment of acute and chronic pain conditions in the ED. The Academic Emergency Medicine consensus conference convened in Dallas, Texas in May of 2014 to develop a research agenda to address this issue among others related to sex differences in the ED. Prior to the conference, experts and stakeholders from emergency medicine and the pain research field reviewed the current literature and identified eight candidate priority areas. At the conference, these eight areas were reviewed and all eight were ratified using a nominal group technique to build consensus. These priority areas were: 1) gender differences in the pharmacologic and non-pharmacologic interventions for pain, including differences in opioid tolerance, side effects, or misuse; 2) gender differences in pain severity perceptions, clinically meaningful differences in acute pain, and pain treatment preferences; 3) gender differences in pain outcomes of ED patients across the lifespan; 4) gender differences in the relationship between acute pain and acute psychological responses; 5) the influence of physician-patient gender differences and characteristics on the assessment and treatment of pain; 6) gender differences in the influence of acute stress and chronic stress on acute pain responses; 7) gender differences in biologic mechanisms and molecular pathways mediating acute pain in ED populations; and 8) gender differences in biologic mechanisms and molecular pathways mediating chronic pain development after trauma, stress, or acute illness exposure. These areas represent priority areas for future scientific inquiry, and gaining understanding in these will be essential to improving our understanding of sex and gender differences in the assessment and treatment of pain conditions in emergency care settings.

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Section: Resultsmentioning

confidence: 54%

Gender Differences in Acute and Chronic Pain in the Emergency Department: Results of the 2014Academic Emergency MedicineConsensus Conference Pain Section

et al. 2014

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“…Headache after ED discharge is quite common—1/3 of migraineurs report moderate or severe headache in the 24 hours following ED discharge and ½ remain functionally disabled[31]. Emergency physicians and others who treat acute headaches are urged to provide their patients with appropriate treatment options for use following discharge.…”

Section: Discussionmentioning

confidence: 99%

Metoclopramide for Acute Migraine: A Dose-Finding Randomized Clinical Trial

Friedman

Mulvey

Esses

et al. 2011

Annals of Emergency Medicine

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Background Intravenous metoclopramide is effective as primary therapy for acute migraine but the optimal dose of this medication is not yet known. Methods This was a randomized, double-blind, dose finding study conducted on patients who presented to our emergency department (ED) meeting International Classification of Headache Disorders criteria for migraine without aura. We randomized patients to 10mg, 20mg, or 40mg of intravenous metoclopramide. We co-administered diphenhydramine to all patients to prevent extra-pyramidal side effects. The primary outcome was improvement in pain on an 11 point Numerical Rating Scale (NRS) at one hour. Secondary outcomes included sustained pain freedom at 48 hours and adverse effects. Results In this study, 356 patients were randomized. Baseline demographics and headache features were comparable among the groups. At one hour, those who received 10mg improved by a mean of 4.7 NRS points (95%CI: 4.2, 5.2); those who received 20mg improved by 4.9 (95%CI: 4.4, 5.4), and those who received 40mg improved by 5.3(95%CI: 4.8, 5.9). Rates of 48 hour sustained pain freedom in the 10, 20, and 40mg groups were: 16% (95%CI:10,24%), 20% (95%CI:14,28%), and 21% (95%CI:15,29%), respectively. The most commonly occurring adverse event was drowsiness, which impaired function in 17% (95%CI: 13,21%) of the overall study population. Akathisia developed in 33 patients. Both drowsiness and akathisia were evenly distributed across the 3 arms of the study. One month later, no patient had developed tardive dyskinesia. Conclusions 20mg or 40mg of metoclopramide are no better for acute migraine than 10mg of metoclopramide.

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“…In our study, as in others, it was difficult to predict headache recurrence based on features of the history of present illness or past headache history. [33–35]. These data suggest that emergency physicians should address the possibility of recurrence when discharging all of their primary headache patients.…”

Section: Discussionmentioning

confidence: 94%

Treating Headache Recurrence After Emergency Department Discharge: A Randomized Controlled Trial of Naproxen Versus Sumatriptan

Friedman

Solórzano

Esses

et al. 2010

Annals of Emergency Medicine

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Background Multiple parenteral medications are used to treat migraine and other acute primary headaches in the emergency department (ED). Regardless of specific headache diagnosis, no medication eliminates the frequent recurrence of primary headache after ED discharge. It is uncertain which medication primary headache patients should be given upon discharge from an ED. The aim of this study was to compare the efficacy of oral sumatriptan to naproxen for treatment of post-ED recurrent primary headache. Methods This was a randomized, double-blind efficacy trial. We randomized patients to either naproxen 500mg or sumatriptan 100mg for headache recurrence following ED discharge. Patients were eligible if they received parenteral therapy for an acute exacerbation of a primary headache in the ED. Patients who met established criteria for migraine without aura were designated a priori as a homogenous subgroup of interest. We followed all patients by telephone 48 hours after ED discharge. The primary endpoint was the between-group difference in change in pain intensity over the 2-hour period following ingestion of either 500 mg naproxen or 100 mg sumatriptan. This difference was measured on a validated 11-point (0–10) verbal Numerical Rating Scale (NRS). Satisfaction with the medication and side effects were also assessed. Patients who met criteria for migraine without aura were analyzed twice according to a priori design: once as a homogenous subgroup and then again combined with all other primary headaches. Results Of 410 patients randomized, 383 (93%) had outcome data available for analysis. 280 (73%, 95%CI: 68, 77% ) reported headache post-ED discharge and 196 (51%, 95%CI: 44, 58%), including 88 with migraine, took the investigational medication provided to them. The naproxen group improved by a mean of 4.3 NRS points, while the sumatriptan group improved by 4.1 (95%CI for difference of 0.2: −0.7, 1.1). Findings were virtually identical among the migraine subset (4.3 vs. 4.2 NRS points, 95%CI for difference of 0.1: −1.3, 1.5). 71% (95%CI: 62, 80%) of naproxen patients and 75% (95%CI: 66, 84%) of sumatriptan patients would want to take the same medication the next time. Side effect profiles were also comparable. Conclusions In this trial, nearly ¾ of patients reported headache recurrence within 48 hours of ED discharge. Naproxen 500 mg and sumatriptan 100 mg taken orally relieve post-ED recurrent primary headache and migraine comparably. Clinicians should be guided by medication costs, contraindications, and a patient’s previous experience with the medication.

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Recurrence of Primary Headache Disorders After Emergency Department Discharge: Frequency and Predictors of Poor Pain and Functional Outcomes

Cited by 43 publications

References 44 publications

Gender Differences in Acute and Chronic Pain in the Emergency Department: Results of the 2014Academic Emergency MedicineConsensus Conference Pain Section

Gender Differences in Acute and Chronic Pain in the Emergency Department: Results of the 2014Academic Emergency MedicineConsensus Conference Pain Section

Metoclopramide for Acute Migraine: A Dose-Finding Randomized Clinical Trial

Treating Headache Recurrence After Emergency Department Discharge: A Randomized Controlled Trial of Naproxen Versus Sumatriptan

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