Trends in the Management of Headache Disorders in US Emergency Departments: Analysis of 2007-2018 National Hospital Ambulatory Medical Care Survey Data

Real-world approaches to outpatient treatment of status migrainosus: A survey study

OBJECTIVES

Identify how the American Headache Society (AHS) membership manages status migrainosus (SM) among outpatients.

BACKGROUND

SM is defined as a debilitating migraine attack lasting more than 72 h. There is no standard of care for SM, including whether a 72-h duration is required before the attack can be treated as SM.

METHODS

The Refractory Headache Special Interest Group from AHS developed a four-question survey distributed to AHS members enquiring (1) whether they treat severe refractory migraine attacks the same as SM regardless of duration, (2) what their first step in SM management is, (3) what the top three medications they use for SM are, and (4) whether they are United Council for Neurologic Subspecialties (UCNS) certified. The survey was conducted in January 2022. Descriptive statistical analyses were performed.

RESULTS

Responses were received from 196 of 1859 (10.5%) AHS members; 64.3% were UCNS certified in headache management. Respondents treated 69.4% (136/196) of patients with a severe refractory migraine attack as SM before the 72-h period had elapsed. Most (76.0%, 149/196) chose "treat remotely using outpatient medications at home" as the first step, 11.2% (22/196) preferred procedures, 6.1% (12/196) favored an infusion center, 6.1% (12/196) sent patients to the emergency department (ED) or urgent care, and 0.5% (1/196) preferred direct hospital admission. The top five preferred medications were as follows: (1) corticosteroids (71.4%, 140/196), (2) nonsteroidal anti-inflammatory drugs (NSAIDs) (50.1%, 99/196), (3) neuroleptics (46.9%, 92/196), (4) triptans (30.6%, 60/196), and (5) dihydroergotamine (DHE) (21.4%, 42/196).

CONCLUSIONS

Healthcare professionals with expertise in headache medicine typically treated severe migraine attacks early and did not wait 72 h to fulfill the diagnostic criteria for SM. Outpatient management with one or more medications for home use was preferred by most respondents; few opted for ED referrals. Finally, corticosteroids, NSAIDs, neuroleptics, triptans, and DHE were the top five preferred treatments for home SM management.

Acute Treatment of Migraine

OBJECTIVE

Most patients with migraine require acute treatment for at least some attacks. This article reviews the approach to the acute treatment of migraine, migraine-specific and nonspecific treatment options, rescue treatment and options for management in the emergency department and inpatient settings, and treatment during pregnancy and lactation.

LATEST DEVELOPMENTS

Triptans, ergot derivatives, and nonsteroidal anti-inflammatory drugs have historically been the main acute treatments for migraine. The development of new classes of acute treatment, including the small-molecule calcitonin gene-related peptide receptor antagonists (gepants) and a 5-HT1F receptor agonist (lasmiditan), expands available options. These new treatments have not been associated with vasospasm or increased cardiovascular risk, therefore allowing migraine-specific acute treatment for the more than 20% of adults with migraine who are at increased risk of cardiovascular events. Neuromodulation offers a nonpharmacologic option for acute treatment, with the strongest evidence for remote electrical neuromodulation.

ESSENTIAL POINTS

The number of available migraine treatments continues to expand, although triptans are still the mainstay of migraine-specific acute treatment. There is no one-size-fits-all acute treatment and multiple treatment trials are sometimes necessary to determine the optimal regimen for patients. Switching within and between classes, using the maximum allowed dose, using combination therapy, and counseling patients to treat early are all strategies that may improve patient response to acute treatment.

Documentation of International Classification of Headache Disorders Criteria in Patient Medical Records: A Retrospective Cohort Analysis

OBJECTIVE

To determine headache diagnosis and treatment patterns in the outpatient setting, focusing on documentation of the International Classification of Headache Disorders (ICHD) criteria.

DESIGN, SETTING, AND PARTICIPANTS

Retrospective cohort data were collected from electronic medical records of adults aged 18-35 who presented to resident-staffed family medicine outpatient clinics in the Midwest, USA, for a new or worsening headache between 2015 and 2016. Diagnosis codes were used to summarize the overall nature and prevalence of headaches. A random subset of 30 patients each for migraine headache (MGH) with and without aura and tension-type headache (TTH) were reviewed to determine how many of the five possible ICHD criteria were documented. Demographics/clinical characteristics, ICHD criteria, number and type of medications, and healthcare utilization (imaging, primary and emergency department care) through one year following the initial visit were summarized and compared across headache types.

RESULTS

There were 716 unique patients during the study period (414 MGH, 227 unspecified headaches, 75 TTH, or others). Complete ICHD criteria were documented for two patients in total. There was partial documentation (e.g., one to four of the possible five) for 30% of TTH, 63% of MGH without aura, and 77% of MGH with aura (p<0.05). Across headache types, patients were prescribed an average of 2.3 to 3.3 medications over one year, with MGH patients generally trying more medications (up to eight for those with aura and up to 12 for those without). Abortive or rescue medications were prescribed to nearly all patients; prophylactics were prescribed for 50% of MGH with aura, 66.7% of MGH without aura, and 53.3%. Non-pharmacologic interventions were less prescribed: 33.3% of TTH patients and 3.3% of MGH types combined (p<0.05). Healthcare utilization was highest for MGH with aura (ED visits) and without aura (clinic visits) patients compared to TTH (p<0.001).

CONCLUSION

Headache-related documentation is often incomplete, which may limit interpretation and associations between diagnoses, prescribing patterns, and healthcare utilization. Future studies should evaluate the use of electronic medical records (EMR)-based templates to improve documentation, and additional detailed studies are needed in the local setting to determine whether treatment, including the use of non-pharmacologic and prophylactic methods of treatment, is optimal.

Emergency department utilization among patients who receive outpatient specialty care for headache: A retrospective cohort study analysis

OBJECTIVES

To compare clinical characteristics among outpatient headache clinic patients who do and do not self-report visiting the emergency department for headache.

BACKGROUND

Headache is the fourth most common reason for emergency department visits, compromising 1%-3% of visits. Limited data exist about patients who are seen in an outpatient headache clinic but still opt to frequent the emergency department. Clinical characteristics may differ between patients who self-report emergency department use and those who do not. Understanding these differences may help identify which patients are at greatest risk for emergency department overutilization.

METHODS

This observational cohort study included adults treated at the Cleveland Clinic Headache Center between October 12, 2015 and September 11, 2019, who completed self-reported questionnaires. Associations between self-reported emergency department utilization and demographics, clinical characteristics, and patient-reported outcome measures (PROMs: Headache Impact Test [HIT-6], headache days per month, current headache/face pain, Patient Health Questionnaire-9 [PHQ-9], Patient-Reported Outcomes Measurement Information System [PROMIS] Global Health [GH]) were evaluated.

RESULTS

Of the 10,073 patients (mean age 44.7 ± 14.9, 78.1% [7872/10,073] female, 80.3% [8087/10,073] White patients) included in the study, 34.5% (3478/10,073) reported visiting the emergency department at least once during the study period. Characteristics significantly associated with self-reported emergency department utilization included younger age (odds ratio = 0.81 [95% CI = 0.78-0.85] per decade), Black patients (vs. White patients) (1.47 [1.26-1.71]), Medicaid (vs. private insurance) (1.50 [1.29-1.74]), and worse area deprivation index (1.04 [1.02-1.07]). Additionally, worse PROMs were associated with greater odds of emergency department utilization: higher (worse) HIT-6 (1.35 [1.30-1.41] per 5-point increase), higher (worse) PHQ-9 (1.14 [1.09-1.20] per 5-point increase), and lower (worse) PROMIS-GH Physical Health T-scores (0.93 [0.88-0.97]) per 5-point increase.

CONCLUSION

Our study identified several characteristics associated with self-reported emergency department utilization for headache. Worse PROM scores may be helpful in identifying which patients are at greater risk for utilizing the emergency department.

Risk of Migraine after Traumatic Brain Injury and Effects of Injury Management Levels and Treatment Modalities: A Nationwide Population-Based Cohort Study in Taiwan

Traumatic brain injury (TBI) causes several long-term disabilities, particularly headaches. An association between TBI and subsequent migraine has been reported. However, few longitudinal studies have explained the link between migraine and TBI. Moreover, the modifying effects of treatment remain unknown. This retrospective cohort study used records from Taiwan's Longitudinal Health Insurance Database 2005 to evaluate the risk of migraine among patients with TBI and to determine the effects of different treatment modalities. Initially, 187,906 patients, aged ≥ 18 years, who were diagnosed as TBI in 2000, were identified. In total, 151,098 patients with TBI and 604,394 patients without TBI were matched at a 1:4 ratio according to baseline variables during the same observation period. At the end of follow-up, 541 (0.36%) and 1491 (0.23%) patients in the TBI and non-TBI groups, respectively, developed migraine. The TBI group exhibited a higher risk of migraine than the non-TBI group (adjusted HR: 1.484). Major trauma (Injury Severity Score, ISS ≥ 16) was associated with a higher migraine risk than minor trauma (ISS < 16) (adjusted HR: 1.670). However, migraine risk did not differ significantly after surgery or occupational/physical therapy. These findings highlight the importance of long-term follow-up after TBI onset and the need to investigate the underlying pathophysiological link between TBI and subsequent migraine.

GAHBT: Genetic-Based Hashing Algorithm for Managing and Validating Health Data Integrity in Blockchain Technology

A method for managing, securing, and validating health data distribution records using a genetic-based hashing algorithm in a decentralized environment is presented in this research report. The rationale for choosing blockchain is to secure the transaction of health data and protect these data from manipulated fraudulent movement and corruption by a contributor to the chain, or any individual. Our approach uses technology that provides an efficient surveillance measure, including transparency of records, immunity from fraud, and protection from tampering, as well as sustaining the order of data. For medical research, the results here provide a genetic-based hashing algorithm for data security, which has lower computational complexity, low space coverage, higher security and integrity, and a high avalanche effect. The simulation will show the validity, immunity, and integrity of the data record. The technique modified in this secure decentralized network is a cryptographic hashing algorithm for 512 bits. In this study, a genetic algorithm (GA) is used to generate a key that must be used in the encryption and decryption of medical data. A GA is a metaheuristic approach inspired by the laws of genetics; and it is generally used to generate high-quality solutions for complex problems. Applications of GAs are possible in medical fields, such as radiology, oncology, cardiology, endocrinology, surgery, oncology, and radiotherapy in healthcare management.