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Between 2007 to the year 2018, the use of opioids drastically decreased among US patients who have headaches. This was a significant decrease in emergency department (ED) visitations, which is in accordance with the guidelines of evidence-based for managing headaches as per analysis results that were published in Journal of Clinical Medicine.

Sudden and severe headaches are responsible for 3.5 millions ED visits each year across the United States, with primary headache conditions (migraine tension-type headache and trigeminal autonomic cerephalalgias) accounting for the majority of them, the authors described.

Patients “often are given unnecessary neuroimaging medication with weak evidence during ED visits because of the difficulty in distinguishing the primary from secondary headaches. insufficient relevant medical histories and a lack of consensus regarding the most effective treatment options in ED environments,” they added.

In order to prevent unnecessary radiation exposure and cut down on healthcare costs It is essential that healthcare providers be cautious and selective in deciding whether or not to perform neuroimaging.

To better know the trends in acute headache treatment within the ED environment, scientists analyzed the characteristics of patients and visitors in the period 2007-2018, using National Hospital Ambulatory Medical Care Survey (NHAMCS) information.

The data are representative of US hospitals and ambulatory care facilities and is collected and disseminated via the US National Center for Health Statistics. The patients in the current study were at minimum 18 years old and had an initial ED diagnosis of headache at the time of discharge Data were aggregated into three time periods which were 2007-2010, 2011,-2014, and 2015-2018.

The 33 million headache related ED visits during the period studied of which one-third (32.9 percent) were caused by migraines, whereas tension migraines as well as trigeminal autonomic cerphalalgias were responsible for 3.2 percent of visits. The remainder were not specified.

“Most related to headaches ED visits were made by patients younger than 50 years old (70.7 percent) female (72.9 percent) and white (70.3 percentage). About half of the headache-related ED visits came from patients with no chronic illnesses (46.3 %),” authors wrote.

Additional analysis showed:

• Opioid use fell from 54.1 percent in 2007-2010 to 28.3 percentage between 2015 and 2018 ( P _trend .001).

• There were statistically significant increasing trends in use of acetaminophen/nonsteroidal anti-inflammatory drugs (NSAIDs), diphenhydramine, and corticosteroids use (all P_trend < .001).
• The changes in butalbital (6.4 percent) and triptan ergot alkaloid (4.7 percent) and antiemetic (59.2 percent between 2015 and 2018) and neuroimaging (37.3 percentage) usage over time were not significant.
• ED visits that included referral to an outpatient for follow-up have increased from 73.3 percentage in 2007-2010, to 79.7 percentage between 2015. ( P _trend = .02).
• The use of neuroimaging remained constant in time (37.3 percent in 2015-2018 [P _Trend = .91(p =.91)).

Over half of visits, 3 or more prescriptions were given and in 54.1 percent of patients, no prescription was given when discharged.

In relation to migraines specifically when compared to other than specified (NOS) headaches the researchers discovered:

• Visits to the doctor for migraine had a higher utilization of triptans/ergot alkaloids (9.7 percent in 2015-2018 vs 1.9 percentage in the period 2015-2018) as well as antiemetics (80.3 percent against 48.3 percent) diphenhydramine (47.5 percent against 30.0 percent) as well as intravenous fluids (48.1 percent and 37.9 percent).
• The use of corticosteroid and Acetaminophen/NSAID appeared to rise more quickly in migraine-related visits.
• The use of neuroimaging in NOS-related headaches was more than twice the rate of migraine-related visits (44.3 percentage vs 23.6 percent between 2015 and 2018).

A number of guidelines issued over the last decade suggest the use of fewer opioids to treat headaches. These guidelines came in conjunction with intensified efforts to combat the epidemic of opioids across the United States at that time.

Many factors could affect a physician’s choice to conduct neuroimaging tests on patients suffering from NOS headache, researchers have noted that “future studies should be conducted to create a reliable and reliable tool for quick screening to detect patients suffering from a primary headache. This tool can be utilized in ED situations.”

Insufficient follow-up information, data to distinguish primary from secondary headaches, as well as the how medications are used in succession are the main limitations of this study. Confounding variables that were not measured could have had an impact on the trends in medication use over time.

In the end, “our study was the first to analyze in depth medical and health care use to treat headaches in the the US EDs, with data that is representative of the entire country,” the authors concluded.

“Future studies are needed in order to find strategies that promote research-based treatment for headaches (eg dexamethasone, sumatriptan, and sumatriptan) and the appropriate referrals to outpatients to follow-up care and reduce unnecessary neuroimaging procedures at EDs,” they said.

Reference

Yang S, Orlova Y, Lipe A, et al. The management of headache-related conditions within US emergency departments Analyzing 2007-2018 national hospital ambulatory health survey of care information. J Clin Med. Published online March 3, 2022. doi:10.3390/jcm11051401