Conference Coverage
Initial treatment with parenteral opiates is associated with an increased length of hospital stay among patients presenting to an emergency department with acute primary headache, according to research published online ahead of print November 3, 2014, in Cephalalgia. This treatment also may be associated with an increased rate of return visits to the emergency department within seven days.
Lucas H. McCarthy, MD, a neurologist at Puget Sound VA Healthcare System in Seattle, and Robert Cowan, MD, Professor of Neurology and Neurological Sciences at Stanford University in California, conducted a retrospective chart review to compare outcomes for patients with acute primary headache initially treated with parenteral opiates or nonopiate recommended headache medications in a large academic medical emergency department (Stanford Emergency Department). Eligible patients were age 18 or older, and the researchers excluded people with any secondary cause for headache.
Recommended Medications
Medications included as recommended in a systematic review of acute migraine treatments and in the Canadian Headache Society guideline for acute migraine treatment in the emergency department were classified as first-line recommended treatments. The list of these drugs included prochlorperazine, metachlopramide, chlorpromazine, ketorolac, aspirin, acetaminophen, triptans, and dihydroergotamine. The researchers analyzed potential confounders such as headache severity, number of medications given, the performance of neuroimaging, duration of hospital stay, and return visits to the emergency department.
Neuroimaging Linked to Early Return Visits
A total of 574 people were included in the final analysis. In all, 303 (52.6%) participants received nonopiate first-line recommended parenteral headache agents as initial agents, and 131 (22.8%) individuals received opiates as initial agents. The remaining 140 (24.4%) patients initially received an alternative parenteral medication.
Median length of hospital stay for all patients was 4.5 hours. Those patients given opiates initially had a univariate 3.9 times higher odds of having a long stay, compared with patients given first-line recommended medications. This association remained significant after the investigators adjusted the results for possible confounders.
Furthermore, 69 participants had at least one readmission for headache during the study period, and 20 individuals returned to the emergency department within seven days. Patients who had neuroimaging had significantly higher rates of early return visits, compared with those who did not have neuroimaging. Approximately 8% of people given opiates had early return visits, compared with 3% of patients given first-line recommended agents. When the investigators added neuroimaging to the multivariable analysis, the association between initial opiate use and early return visits was no longer significant.
The association between longer length of stay and initial opiate use likely reflects a class effect, because “opiates have shown less headache pain reduction, higher rates of headache recurrence, and increased sedation, compared with first-line recommended specific headache medications,” said Dr. McCarthy. The authors acknowledged that the retrospective nature of the study limited their ability to establish cause and effect, however. “Encouraging the initial use of first-line recommended headache medications rather than opiates in all acute primary headaches (regardless of migraine diagnosis) … could improve patient outcomes,” they concluded.
Acute Diagnosis May Not Be Necessary
“Regardless of whether the acute headache takes the form of migraine or tension-type headache, it is likely to respond to most nonopioid parenteral treatments, including subcutaneous sumatriptan, metoclopramide, and ketorolac,” said Benjamin W. Friedman, MD, Associate Professor in the Department of Emergency Medicine at Albert Einstein College of Medicine in the Bronx, New York, and David R. Vinson, MD, of Kaiser Permanente Sacramento Medical Center in California, in an accompanying editorial. “We do our best to provide our patients with a specific diagnosis, but because the vast majority of primary headaches in the emergency department take the form of migraine or tension-type headache, diagnosis is not necessary acutely.
“The most important intervention emergency physicians can deliver for their headache patients is to connect them with outpatient physicians savvy about headache management, who will then provide these headache patients with appropriate acute therapeutics, initiate preventive therapy, and counsel their patients against receiving opioids in the emergency department,” Dr. Vinson concluded.
—Erik Greb