(P-066) Trends in the Management of Primary Headache in US Emergency Departments: Analysis of 2007-2018 NHAMCS Data

Background: Prior studies reported that patients often receive unnecessary neuroimaging or medications with low-quality evidence for primary headache (PH) management in emergency departments (EDs). Thus, the American Headache Society released the “Choosing Wisely Campaign” discouraging unnecessary neuroimaging and opioid use for uncomplicated headaches in 2013. Little is known about the changes in PH management in EDs due to these treatment recommendations in the United States (US).

Objectives: To examine the trends in the management of PH in EDs from 2007-2018.

Methods: This cross-sectional analysis used 2007-2018 National Hospital Ambulatory Medical Care Survey data. We included patient visits (≥18 years) with a primary ED discharge diagnosis of PH including migraine, tension-type, cluster, and not otherwise specified (NOS) headache. We classified headache medications by pharmacological class: opioid analgesics, ergots/triptans, antiemetics, antihistamines, acetaminophen/non-steroidal anti-inflammatory drugs (NSAIDs), corticosteroids, and intravenous fluids. To obtain reliable estimates, we merged data into 3 time periods: 2007-2010, 2011-2014, and 2015-2018. We used multivariable logistic regression to examine the trends in medication use, neuroimaging use, and referral to physician/clinic for follow-up, separately.

Results: Of 33 million PH-related ED visits in 2007-2018, the majority were NOS headaches (63.9%) followed by migraine (32.9%). The majority of PH-related ED visits in 2015-2018 were from patients aged <50 years (70.7%), female (72.9%), and White (70.3%). Among PH-related ED visits, opioid use decreased from 54.1% in 2007-2010 to 28.3% in 2015-2018 (p < 0.001). Increased trends were observed (all p<0.001) in the use of antiemetics (39.2% in 2007-2010 to 50.1% in 2015-2018), acetaminophen/NSAIDs (37.2% to 52.4%), and corticosteroids (2.7% to 6.2%). Ergot/triptan (4.7%, p=0.87) and neuroimaging (37.3%, p=0.90) use remained stable over time. PH-related ED visits with physician/clinic referrals increased slightly from 73.3% in 2007-2010 to 79.7% in 2015-2018 (p=0.04).

Conclusions: Reflecting evidence-based guideline recommendations for headache management, opioid analgesic use substantially decreased from 2007 to 2018 among US PH-related ED visits. Non-opioid medication use (e.g., NSAIDs) and referrals to a physician/clinic increased significantly, while ergot/triptan use and visits with neuroimaging orders remained stable. Future studies are warranted to identify strategies to promote evidence-based treatment for PH and immediate outpatient referrals and reduce unnecessary neuroimaging orders in EDs.