Treatment of primary headache in the emergency department

Each year many patients present to an emergency department for treatment of acute primary headache. We investigated the diagnosis and clinical outcome of patients treated for primary headache in the emergency department.

Patients treated for acute primary headache in the emergency department completed a questionnaire related to their headache symptoms, response to treatment, and ability to return to normal function. These responses were compared to the treating physicians' observations of the patient's condition at the time of discharge from the emergency department.

Based on the questionnaire, 95% of the 57 respondents met International Headache Society diagnostic criteria for migraine. Emergency department physicians, however, diagnosed only 32% of the respondents with migraine, while 59% were diagnosed as having "cephalgia" or "headache NOS" (not otherwise specified). All patients previously had taken nonprescription medication, and 49% had never taken a triptan. In the emergency department, only 7% of the patients received a drug "specific" for migraine (ie, a triptan or dihydroergotamine). Sixty-five percent of the patients were treated with a "migraine cocktail" comprised of a variable mixture of a nonsteroidal anti-inflammatory agent, a dopamine antagonist, and/or an antihistamine; 24% were treated with opioids. All 57 patients reported that after discharge they had to rest or sleep and were unable to return to normal function. Sixty percent of patients still had headache 24 hours after discharge from the emergency department.

The overwhelming majority of patients who present to an emergency department with acute primary headache have migraine, but the majority of patients receive a less specific diagnosis and a treatment that is correspondingly nonspecific.