Analysis of headache management in a busy emergency room in the United States

To analyze the demographics, diagnosis, and treatment patterns in patients with headache-seeking treatment in one of the busiest emergency rooms (ER) of an academic medical center in the USA.

The past decade has seen tremendous improvement in acute and preventive management of headaches. However, there are very few data on how headache patients are managed by ER doctors.

Retrospective analysis of 100 charts chosen at random for patients with a discharge diagnosis of headache (according to ICD-9 codes) from the University of Southern California + Los Angeles County Hospital ER.

The majority of patients were female (74%) and Hispanic (76%) with an age range of 15-68 years. The most common ER diagnoses were migraine (42%) and headache not otherwise specified (headache NOS - 42%). Fifty-one percent of patients received a head computerized tomography; 9% received a lumbar puncture. Medications most frequently used for acute treatment, whether migraine or headache NOS, were narcotics (25%), followed by antiemetics (24%), nonsteroidal anti-inflammatory drugs (19%), and acetaminophen (17%). Only 5% of migraine patients received migraine-specific triptans in the ER (2% overall). Thirty-one percent of migraineurs were given a prescription for a triptan upon discharge from the ER (17% of all patients). Eighteen percent of patients were admitted to the hospital with secondary headache. The final diagnosis in the ER matched the diagnosis of the neurologist in 79% of cases with a moderate degree of agreement.

Narcotics remain the medications most often chosen for treatment of all acute headaches (including migraine) in the ER. There is very little use of migraine-specific medications in the ER. In addition, neurology consults are underutilized even in an academic setting in the ER. The data suggest a lack of clear standards of care for diagnosis and treatment of headache, especially migraines. Specific guidelines for headache management should be established keeping in mind the unique setting of the ER.