The Headache in Emergency Departments study: Opioid prescribing in patients presenting with headache. A multicenter, cross‐sectional, observational study

Abstract

Objective To describe the patterns of opioid use in patients presenting to the emergency department (ED) with nontraumatic headache by severity and geography. Background International guidelines recognize opioids are ineffective in treating primary headache disorders. Globally, many countries are experiencing an opioid crisis. The ED can be a point of initial exposure leading to tolerance for patients. More geographically diverse data are required to inform practice. Methods This was a planned, multicenter, cross‐sectional, observational substudy of the international Headache in Emergency Departments (HEAD) study. Participants were prospectively identified throughout March 2019 from 67 hospitals in Europe, Asia, Australia, and New Zealand. Adult patients with nontraumatic headache were included as identified by the local site investigator. Results Overall, 4536 patients were enrolled in the HEAD study. Opioids were administered in 1072/4536 (23.6%) patients in the ED, and 386/3792 (10.2%) of discharged patients. High opioid use occurred prehospital in Australia (190/1777, 10.7%) and New Zealand (55/593, 9.3%). Opioid use in the ED was highest in these countries (Australia: 586/1777, 33.0%; New Zealand: 221/593, 37.3%). Opioid prescription on discharge was highest in Singapore (125/442, 28.3%) and Hong Kong (12/49, 24.5%). Independent predictors of ED opioid administration included the following: severe headache (OR 4.2, 95% CI 3.1–5.5), pre‐ED opioid use (OR 1.42, 95% CI 1.11–1.82), and long‐term opioid use (OR 1.80, 95% CI 1.26–2.58). ED opioid administration independently predicted opioid prescription at discharge (OR 8.4, 95% CI 6.3–11.0). Conclusion Opioid prescription for nontraumatic headache in the ED and on discharge varies internationally. Severe headache, prehospital opioid use, and long‐term opioid use predicted ED opioid administration. ED opioid administration was a strong predictor of opioid prescription at discharge. These findings support education around policy and guidelines to ensure adherence to evidence‐based interventions for headache.

Characterizing opioid use in a Dutch cohort with migraine

“…While a cross-sectional study in the US showed that opioid use decreased from 2007 to 2018 among headache-related ER visits, it is still high (up to 28%) (25). The frequency of opioid prescription for nontraumatic headache in the emergency department and at hospital discharge varies internationally, but there are hardly any data on the situation in Europe (26,27) Severe headache, prehospital opioid use, and long-term opioid use predicts opioid administration at the emergency department. Opioid administration at the emergency department is also a strong predictor of opioid prescription at discharge (26).…”

“…The frequency of opioid prescription for nontraumatic headache in the emergency department and at hospital discharge varies internationally, but there are hardly any data on the situation in Europe (26,27) Severe headache, prehospital opioid use, and long-term opioid use predicts opioid administration at the emergency department. Opioid administration at the emergency department is also a strong predictor of opioid prescription at discharge (26). There is still major concern towards an underutilization of triptans and overutilization of opioids, and there is still a non-adherence to hospital or evidence-based established international guidelines (28).…”

Knowledge of the medical resident about diagnosis and treatment of patients with headache

“…This justifies the little knowledge many residents have about the use of morphine derivatives in the treatment of patients with headache, which is contraindicated. [16][17][18] This is a wrong practice that is still done in many countries. 18 Concepts such as defining chronic daily headache and analgesic overuse headache were not known by all residents.…”

“…[16][17][18] This is a wrong practice that is still done in many countries. 18 Concepts such as defining chronic daily headache and analgesic overuse headache were not known by all residents. The participation of undergraduate medical students in academic leagues has decreased this teaching deficit.…”

Primary headache drug treatment in emergency departments in Australia and New Zealand

“…Treating acute headache begins at home and continues, if necessary, in the emergency department (ED). Drug treatment is heterogenous, 1 and understanding the determinants of prescribing could help appropriate medication choices. We therefore assessed the predictors of prescribing in Australian and New Zealand EDs for people with primary headache.…”