Headache evaluation and treatment by primary care physicians in an emergency department in the era of triptans.

BACKGROUND

Despite advances in treatment, patients with migraine have been underdiagnosed and undertreated.

METHODS

Documentation of visits by patients with headache to an urgent care department staffed by primary care physicians was reviewed. Patients were also sent a brief headache screen, and those who replied were interviewed by telephone. "Repeaters" (patients who made 3 or more visits in 6 months) were excluded from chart review.

RESULTS

Over 6 months, 518 patients made 1004 visits to the emergency department for primary headache complaints: 464 patients (90%) made 1 or 2 visits (total visits, 502). A review of 174 charts documenting a diagnosis of migraine found that (1) the need for prophylaxis was determined in only 40 (31%) of the patients who were not already undergoing prophylaxis and (2) treatment in the emergency department was migraine specific in 46 patients (26%) or otherwise appropriate in 45 (25%). A review of 90 charts documenting nonmigraine diagnoses found that 30 patients (33%) had adequate history documented to exclude migraine as the diagnosis. Eighty-six patients (17%) were interviewed. An emergency department diagnosis of migraine (n = 59) corresponded to a final diagnosis of migraine with (n = 21) or without (n = 18) medication overuse or chronic daily headache and/or transformed migraine with (n = 18) or without (n = 2) medication overuse. Discharge diagnoses that were not migraine (n = 27) had final diagnoses of migraine with (n = 9) or without (n = 9) medication overuse or chronic daily headache/transformed migraine with (n = 7) or without (n = 2) medication overuse.

CONCLUSIONS

In this emergency department population, many patients with migraine, chronic daily headache, or medication overuse are not accurately diagnosed. The need for prophylaxis is not usually assessed. Treatment is migraine specific in the minority of patients. Tension-type headache is rarely an accurate diagnosis in this emergency department population.