Addressing and Assessing Migraine in the Emergency Department

February 2, 2020

The director of headache services at NYU Langone discussed the 2019 American College of Emergency Physicians guidelines on acute nontraumatic headache in the emergency department.

Mia T. Minen, MD, MPH

In July 2019, the American College of Emergency Physicians (ACEP) released new guidelines for the diagnosis and management of acute nontraumatic headache in the emergency department (ED), with a heavy focus on subarachnoid hemorrhage and the use of imaging and lumbar puncture in diagnosis.

This month, the American Headache Society released a commentary on these guidelines with the intent of supplementing and supporting the ACEP’s recommendations. One of the authors of that response was Mia T. Minen, MD, MPH, chief, headache research, and assistant professor, departments of Neurology and Population Health, NYU Langone Medical Center.

To find out more about the AHS’s position on headache and migraine treatment tin the ED and the relationship between headache specialists and their emergency medicine counterparts, NeurologyLive spoke with Minen.

NeurologyLive: Could you provide some context to the AHS’s response to the ACEP guidelines?

Mia T. Minen, MD, MPH: The ACEP developed very specific guidelines that they said were for the preventive presenting ED acute headache in the title, and that I think that from a headache specialist perspective, there is a wider differential for various diagnoses that could be causing an acute headache that still need to be assessed in the ED if somebody is coming in with an acute headache. When you are developing guidelines, there is supposed to be a very, generally, narrow scope in the questions so that you're able to appropriately answer them. But I think what happened was in their guidelines, they really focused more on subarachnoid hemorrhage, and risk stratification, and management of that. However, the American Headache Society perspective is that acute headache is not just subarachnoid hemorrhage, there are other things that need to be evaluated.

Do you feel that the ACEP guidelines appropriately addressed the challenge of opioid use to address migraine in emergency medicine? Or is that still an existing problem?

It's a huge issue nationally, where patients are just being given a diagnosis of headache and being given opioids or nonspecific treatments because physicians aren't going the extra step to making that diagnosis of migraine, say, and then treating appropriately and accordingly. Or even if they make the diagnosis of migraine, they're not comfortable treating it and they're more comfortable just using opioids, ironically, because they're more used to prescribing them.

I think that we agreed with the ACEP recommendation, and that appears to not be the preferred treatment. We also just wanted to emphasize that, in addition to the whole opioid epidemic and concern for opioid use and abuse. There's also, within headache medicine, a concern for medication overuse headache, and the idea that just 5 to 8 tablets have an opioid may actually lead to worse and headaches in the end—and that's different from the opioid use for back pain or some other kind of pain condition. In the case of headache medicine, people wind up also getting medication overuse headache, so it can worsen the headache that the patients are suffering from and presenting with.

Do you feel that the communication between the ED and headache specialists is where it should be? Are there any current pain points or concerns?

I think that it really varies across the country. But I think that there's always room for improvement and that there could be much-improved efforts of communication between the neurologists and the emergency room doctors in developing protocols and things like that. Also for coordinating care—and we've published on that—where patients go to ED for a headache and the physician isn't contacted, they don't get the results or reports or anything in terms of what happened in the ED. There's not really much crosstalk between the ED and neurology in terms of coordination of care efforts for these patients post-ED discharge.

Are there issues with opioids being administered in the emergency room for migraine and what factors are driving that?

That’s the main issue—the education. There's a lack of, or not enough, sufficient education regarding the various evidence-based treatment options, and I think part of the response was also stating that there are clear guidelines from the American Headache Society that were done in accordance with the American Chemists Neurology guideline methodology, stating which medications are preferred in the ED. We know that, unfortunately, ED physicians are still not using these medications.

In terms of additional medications beyond the guidelines, for sure, there are medications like DHE, where there are high number of EDs in the country that are not comfortable administering DHE. In terms of the new medications, so far, they have not been administered in the ED setting, and I think that, first, we need further education on the part of the emergency room doctors in terms of even the more established medications that could work. Then there can be further investigations into whether some of the newer medications might also be effective in the ED setting.

Do you have any advice for your colleagues in the ED on how to approach migraine?

Migraine is extremely disabling. It's the second most disabling condition for the World Health Organization. So, while it's not a life-threatening situation—and that's what ED physicians are really focused on: Is the patient going to die or not die? How do we stabilize them, and get them admitted if they're not sick? While it's not that severity in terms of life-threatening illness, it is the second most disabling condition, and therefore, even if patients are sent home, they're still going to be having low healthcare utilization rates, whether it's ED recidivism, or they’re going on to multiple other care providers.

The key thing for the ED doctors is to really ask about nausea and vomiting. If somebody has migraine and nausea and vomiting, then to think like they probably are going to need an anti-nausea medicine, otherwise, they're going to wind up back in the ED or need be hydrated, etc, and have other complications. Telling somebody to take an acetaminophen or ibuprofen or whatever on the outside of the hospital is not really the recommended treatment for moderate to severe attacks. Therefore, they should be more comfortable also giving medications on discharge, such as triptans, to try to prevent revisit. I think educating them about making that diagnosis, but also recognizing the specific symptoms and making sure that you're giving them the tools on discharge, is the key thing.

Do you have anything you’d like to add on the topic?

I'm really interested in this—it is one of my areas of expertise. I'm really interested actually in the growth of urgent care settings now, nationally, as a potential alternative to for migraine patients, as opposed to going to the ED. I think that the key thing is if we can coordinate with neurologists or headache specialist in these urgent care settings, to have good recognition for diagnosing migraines and treatment protocols, etc.—that’s a win-win situation. That would be a great value to neurologists and headache specialists because if patients have an acute migraine and need some IV treatment or need an infusion, these Urgent Care centers are open 7 days a week, evenings, so it's an opportunity for patients to go there to get the treatments as opposed to going to the ED and suffering long periods of wait time and depleted treatment. We're sending those with migraine symptoms to high-cost ED care.

We just published an article a short time ago evaluating the 2 urgent care centers at NYU for migraine, and we have another study that's in submission right now looking at 67 urgent care centers in New York City in terms of like headache diagnoses, migraine, revisit rates, and time to revisit. In terms of the future, I think resources should really be developed and devoted to helping these urgent care centers around the country to optimize headache management.

Is the urgent care model a model that could be followed across the country?

They're pretty widespread. That being said, there's some data to show they're more heavily concentrated in certain socio-economic areas. But they are pretty much national. They're not so uniform right now, but I'm not sure that's so different from EDs. In fact, you might be able to argue that the urgent cares might be more uniform just because they are companies that have so many urgent cares, as opposed to like one hospital versus another hospital. I think we still are really trying to better understand the landscape which, is why I did those 2 studies and really, there was nothing published at all before.

I think time will tell. With further information, I do think that hopefully there will be ways of uniting and educating these doctors. I will say that includes doctors and other frontline providers from varied specialties. Sometimes there are emergency room doctors, but sometimes they are primary care or family physicians, and there are also PAs and NPs on staff at these urgent care centers, so I think it's going to have to be like a multi-provider kind of approach to treatment. It's not just going to be like one society, for example, in terms of educating them.

Transcript edited for clarity.

REFERENCE

Perentz A, Dujari S, Cowan R, Minen M. ACEP Guidelines on Acute Nontraumatic Headache Diagnosis and Management in the Emergency Department, Commentary on Behalf of the Refractory, Inpatient, Emergency Care Section of the American Headache Society. Headache. Published online January 2020. doi: 10.1111/head.13744.