Friedman Benjamin W, Mistry Binoy, West Jason R, Wollowitz Andrew
Department of Emergency Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY, USA; Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
Department of Emergency Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY, USA; Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
Am J Emerg Med. 2014 Sep;32(9):976-81. doi: 10.1016/j.ajem.2014.05.017. Epub 2014 May 20.
Elevated blood pressure (BP) and headache have long been linked in the medical literature, although data on association are conflicting. We used previously collected data to address these related aims: (1) using the National Hospital Ambulatory Medical Care Survey (NHAMCS), we determined whether elevated BP is more likely in patients who present to an emergency department (ED) with headache than in patients who present with other complaints; (2) using data collected in 3 ED-based migraine clinical trials, we determined the association between improvement in headache pain and improvement in BP among patients who present to an ED with migraine and elevated BP; (3) using the data from the migraine clinical trials, we also determined if an elevated baseline BP identifies a group of patients less likely to respond to standard migraine treatment.
We analyzed 2 distinct data sets. The first, NHAMCS, is a national probability sample of all US ED visits. The second is a compilation of data gathered during 3 ED-based migraine randomized controlled trials. We defined elevated BP as follows: moderate elevation-systolic BP (SBP) ≥150 mm Hg or diastolic BP (DBP) ≥95 mm Hg; marked elevation-SBP ≥165 mm Hg or DBP ≥100 mm Hg; and severe elevation-SBP ≥180 mm Hg or DBP ≥110 mm Hg. We report the association between headache and elevated BP in NHAMCS using odds ratios (ORs) with 95% confidence intervals (CI). We report the correlation coefficient and r(2) for the association between improvement in BP and improvement in headache pain in our clinical trials data set. Finally, using our clinical trials database, we determined the influence of elevated BP at baseline on response to migraine medication by constructing a linear regression model in which the dependent variable was improvement in 0 to 10 pain score between baseline and 1 hour, and the primary predictor variable was presence or absence of elevated BP at baseline.
Headache was the primary complaint in 3.7% (95% CI, 3.4-4.0%) of all US ED visits, corresponding to 4.8 million (95% CI, 4.2-5.4 million) patient visits. Among US ED patients, those with headache were more likely than patients with other chief complaints to have markedly (OR, 1.37; 95% CI, 1.16-1.61) or severely elevated BP (OR, 1.49; 95% CI, 1.17-1.90). In our clinical trials data set of patients with migraine with moderately elevated BP, there was no correlation between improvement in pain score and improvement in SBP (r = -0.07, r(2) = 0, P = .465) or DBP (r = -0.03, r(2) = 0, P = .75). Similarly, there was no correlation between improvement in headache and improvement in BP among patients with migraine with markedly elevated BP (for SBP, r = -0.19, r(2) = 0.04, P = .89; for DBP, r = -0.02, r(2) = 0, P = .87), nor among patients with severely elevated BP (for SBP, r = 0.06, r(2) = 0, P = .81; for DBP, r = 0.03, r(2) = 0, P = .90). Patients with moderately elevated BP had slightly less improvement in their 0 to 10 pain score than patients with BPs below this cutoff (-0.6; 95% CI, -1.2 to -0.1; P = .03). This was more pronounced among patients with markedly elevated BP (-0.9; 95% CI, -1.7 to -0.2).
Although there is an association between elevated BP and headache among patients presenting to an ED, improvement in headache is not associated with improvement in BP.
血压（BP）升高与头痛在医学文献中早有联系，尽管关于二者关联的数据相互矛盾。我们利用先前收集的数据来实现以下相关目标：（1）通过国家医院门诊医疗调查（NHAMCS），我们确定了因头痛前往急诊科（ED）就诊的患者比因其他主诉就诊的患者血压升高的可能性是否更高；（2）利用在3项基于急诊科的偏头痛临床试验中收集的数据，我们确定了因偏头痛和血压升高前往急诊科就诊的患者中，头痛疼痛改善与血压改善之间的关联；（3）利用偏头痛临床试验的数据，我们还确定了基线血压升高是否能识别出一组对标准偏头痛治疗反应较差的患者。
我们分析了2个不同的数据集。第一个是NHAMCS，它是美国所有急诊科就诊的全国概率样本。第二个是在3项基于急诊科的偏头痛随机对照试验中收集的数据汇编。我们将血压升高定义如下：中度升高——收缩压（SBP）≥150 mmHg或舒张压（DBP）≥95 mmHg；显著升高——SBP≥165 mmHg或DBP≥100 mmHg；重度升高——SBP≥180 mmHg或DBP≥110 mmHg。我们在NHAMCS中使用比值比（OR）及95%置信区间（CI）报告头痛与血压升高之间的关联。我们在临床试验数据集中报告血压改善与头痛疼痛改善之间关联的相关系数和r²。最后，利用我们的临床试验数据库，通过构建一个线性回归模型来确定基线血压升高对偏头痛药物反应的影响，其中因变量是基线至1小时之间0至10分疼痛评分的改善情况，主要预测变量是基线时是否存在血压升高。
头痛是所有美国急诊科就诊患者中3.7%（95%CI，3.4 - 4.0%）的主要主诉，相当于480万（95%CI，420万 - 540万）次患者就诊。在美国急诊科患者中，头痛患者比其他主要主诉患者更有可能出现显著（OR，1.37；95%CI，1.16 - 1.61）或重度血压升高（OR，1.49；95%CI，1.17 - 1.90）。在我们的中度血压升高偏头痛患者临床试验数据集中，疼痛评分改善与SBP改善（r = - 0.07，r² = 0，P = 0.465）或DBP改善（r = - 0.03，r² = 0，P = 0.75）之间无相关性。同样，在显著血压升高的偏头痛患者中，头痛改善与血压改善之间无相关性（对于SBP，r = - 0.19，r² = 0.04，P = 0.89；对于DBP，r = - 0.02，r² = 0，P = 0.87），在重度血压升高的患者中也无相关性（对于SBP，r = 0.06，r² = 0，P = 0.81；对于DBP，r = 0.03，r² = 0，P = 0.90）。中度血压升高的患者在0至10分疼痛评分上的改善略低于血压低于此临界值的患者（-0.6；95%CI，-1.2至 - 0.1；P = 0.03）。这在显著血压升高的患者中更为明显（-0.9；95%CI，-1.7至 - 0.2）。
尽管在前往急诊科就诊的患者中血压升高与头痛之间存在关联，但头痛的改善与血压的改善无关。
