Treatment of Headache in the ED

Transcription

1 Treatment of Headache in the ED Benjamin W. Friedman, MD, MS, FAAEM Associate professor of Emergency Medicine Albert Einstein College of Medicine Montefiore Medical Center

2 Disclosure

3 Topics of Discussion 1) Why don t we use triptans in the ED (and should we?) 2) An ED specific nosology & the unobtainable goal of diagnostic clarity 3) Opioid wars: The frequent flyers

4 Why don t we use triptans in the ED Why don t we use triptans in the ED (and should we)?

5 Case 36y woman with typical headache x 18 hrs Started gradually at work yesterday Severe, occipital, bilateral, throbbing, with nausea. No relief with ibuprofen 800mg, naproxen 500mg, acetaminophen 1500mg, hydrocodone/ acetaminophen x 2 PMH: Migraine without aura; 3 previous ED visits for migraine Usually uses ibuprofen 2x/ month (with relief), PE: Unremarkable including normal cranial nerve exam, normal PE: Unremarkable including normal cranial nerve exam, normal visual acuity, and normal retinal exam

6 Treatment of migraine in US EDs Medication Any parenteral opioid 53% 51% Meperidine 7% 37% Hydromorphone 26% <1% Morphine 10% 1% Ketorolac 34% 16% Promethazine 33% 27% Metoclopramide 17% 3% Prochlorperazine 15% 16% Any triptan 7% 10% Dihydroergotamine 1% 3% Dexamethasone 8% 0% Friedman, West, Vinson, et.al. Cephalalgia. 2014

7 Why don t EPs use triptans? Content with current practice: what I use works Lack of exposure- Don t know/ don t trust Contra-indications- 39% of ED HA patients with elevated BP at triage 1 Unknown pregnancy status Unknown risk for coronary heart disease Demanding patients Fear of side effects 1. Gupta M. AHS June, 2005

8 Sumatriptan 2hr relief Drug, dose # of studies # improved with triptan # improved with placebo NNT Sumatriptan, 6mg, SQ 8 379/477 (79%) 131/461 (28%) 2.0 (1.8, 2.2) Oldman, Pain, 2002

9 All the triptans- 2hr headache relief Oldman, Pain, 2002

10 Efficacy of sumatriptan Subcutaneous sumatriptan, 6mg Meaningful relief Time to meaningful relief (median) Suma 75% 34 min 67% Placebo 35% NA 92% 24 hour recurrence (in those with relief) Adverse effects: 52% of Suma group (vs 27% of placebo). Dizziness, vertigo, paresthesias. 5 reported tdchest ttightness, heaviness, or numbness Akpunonu BE. Ann Emerg Med 1995;25(4):464 9

11 Metoclopramide versus Sumatriptan 6mg SQ MCP (n=40) Suma (n=38) Sumatriptan 6mg SQ Metoclopramide 20mgIV q 30m +DPH 2hr pain free 59% 36% Could resume normal activities 85% 69% Friedman, Neurology, 2005

12 Metoclopramide versus Sumatriptan 6mg SQ MCP 10mg IV Vs Sumatriptan (n=40) 60 min pain free: MCP: 65% Suma: 45% NNT=5 Esteban Morales 1999 MCP 20mg IV Vs Sumatriptan (n=124) MCP improves on average 1.1 more than Suma (0-10 scale) Talabi. Journal of Research in Medical Sciences. 2013

13 IV prochlorperazine 10mg + diphenhydramine 12.5mg Vs. Subcutaneous sumatriptan 6mg The mean decrease in pain intensity it in the IV prochlorperazine with diphenhydramine group was 73 mm compared with 50 mm in the subcutaneous sumatriptan group (difference=23 mm; 95% CI 11 to 36 mm). Kostic, A Emerg Med, 2010

14 Droperidol Droperidol 2.75mg IM Droperidol 8.25mg IM Droperidol 5.5mg IM Droperidol 0.1mg IM Placebo Silberstein., Neurology,

15 Haloperidol 5mg IV versus placebo Includes those who did not respond to n=20 n=20 n=24 placebo and others who did not consent for RCT

16 Chlorpromazine 0.1 mg/kg g vs placebo Migraine without aura Placebo n=30 Chlorpromazine n=30 Migraine with aura Placebo n=30 Pain Free at 30 3% 21% 0 37% minutes Chlorpromazine n=30 Pain Free at 60 10% 63% 7% 67% minutes Pain free at 24 hours 47% 74% 73% 90% Bigal, Journal of EM, 2002

17 Treatment of migraine: anti-dopaminergics Underappreciated/ underutilized for migraine Extensive clinical evidence base for these medications as primary treatment of migraine (mostly parenteral). Clinical data has outpaced basic science

18 Anti-histamines? Sustained relief (48 hours) Diphenhydramine Placebo Difference (95%CI) 41/99 39/103 4% (41%) (38%) ( 10, 17%)

19 Adverse events AE Diphenhydramine h Placebo Difference (95%CI) Very restless 8/99 7/102 1% (8%) (7%) ( 6, 8%) More Benadryl 6/104 (6%) 8/ 103 (8%) 2% ( 5, 9%)

20 Dexamethasone Colman. BMJ. 2008

21 AHS: Management of Adults with Acute Migraine in the Emergency Department Intravenous metoclopramide and prochlorperazine, and subcutaneous sumatriptan should be offered to eligible adults who present to an ED with acute migraine (Should offer Level B) Dexamethasone should be offered to these patients to prevent recurrence of headache (Should offer Level B) Because of lack of evidence demonstrating efficacy and concern about sub-acute or long-term sequelae, injectable morphine and hydromorphone are best avoided as first-line therapy (May avoid--level C)

22 Case 36y woman with typical headache x 18 hrs Started gradually at work yesterday Severe, occipital, bilateral, throbbing, with nausea. No relief with ibuprofen 800mg, naproxen 500mg, sumatriptan 100mg x 2 Akathisia after previous treatment with metoclopramide PMH: Migraine without aura; 3 previous ED visits for migraine Usually uses ibuprofen 2x/ month (with relief) PE: Unremarkable including normal cranial nerve exam, normal visual acuity, and normal retinal exam

23 How I treat migraine 1. Metoclopramide 2. Dexamethasone 3. Metoclopramide + ketorolac 4. Metoclopramide + DHE 5. GONB 6. Percocet? MOH? Chronic migraine? Psychiatric co-morbidities

24 An ED specific nosology & the unobtainable An ED specific nosology & the unobtainable goal of diagnostic clarity

25 How should I treat this patient? 36 year female presents with acute exacerbation of recurrent headache disorder x 12 hours. Similar to previous. Never been given a specific diagnosis. No relief with Advil 600mg 12 hours ago. RoS otherwise negative. Physical exam is noncontributory. Patient A -Left frontal -Throbbing -Associated with nausea Patient B -Bifrontal -Pressure/ tightness -Associated with nausea Patient C -Bifrontal -Pressure/ tightness -No associated symptoms

26 Diagnostic clarity Badness: Tumor, aneurysm, meningitis Migraine Tension-type headache Sinus headache Hypertensive headache

27 Diagnostic reality A cohort study of 480 patients Friedman, Hochberg, Esses, etal Annals Emergency Medicine 2007

28 Treatment of primary headaches Diagnosis Treatment Treatment Diagnosis

29 Metoclopramide 10mg IV Migraine (n=50) Tension-type (n=35) Improvement after 45 minutes 85% 81% Needed rescue medication 14% 14% Cicek M, Karcioglu O, Parlak I, et.al. EMJ, (3): 323-6

30 Sumatriptan 6mg SQ Migraine Tension-type (n=84) (n= 18) Baseline pain score (0-100) Improvement at 30 min 35% 38% Improvement at 60 min 57% 60% Miner, American Journal of Emergency Medicine, 2007

31 TTH Outcome Ketorolac Metoclopramide Difference 30mg IV 10mg (95%CI) Sustained freedom 9% 26% 17% (2, 32%) Friedman. Ann Emerg Med. 2013

32 TTH Medication Pain free 60 min Pain free 24 hours Chlorpromazine 0.1 mg/kg (n=30) 70% 87% Placebo (n=30) 20% 63% Bigal, Arq Neuropsiquiatr, 2002

33 How should I treat this patient? 36 year female Patient A -Left frontal -Throbbing -Associated with nausea Patient B -Bifrontal -Pressure/ tightness -Associated with nausea Patient C -Bifrontal -Pressure/ tightness -No associated symptoms Discuss differential diagnosis at time of discharge

34 Opioid wars & the Frequent Flyers

35 The case 36y woman, presents with her typical migraine headache 12 days of migraine/ month Sumatriptan and ibuprofen usually give relief 2 ED visits/ month for severe migraine refractory to oral treatment Presents with 10/10 severe pain for 6 hours Doc, just give me my Demerol

36 Opioids for treatment of headache in the ED The debate: Oligoanalgesia versus problematic behavior Oligoanalgesia: Underuse of analgesics in face of valid indication Problematic behavior: Drug-seeking and ED recidivism (inappropriate use of medical treatments and resources)

37 Reasons not to use opioids 1. Bouncebacks/ recidivism 2. Back to work 3. Chronification 4. Refractory to triptans Colman, Neurology, 2004; Bigal, Headache, 2008; Jakubowski, Headache, 2005; Ho, Headache, 2009

38 Therefore: 1. In opioid naïve patients: 2. In patients who request opioids: 3. In patients who insist on opioids: 4. In patients who frequently present to ED and insist on opioids:

39 Problematic patients Screen for interventions Outpatient provider Medication overuse headache Preventives Rule out secondary headache! Problematic patient committees Department wide policy/ Patient specific interventions to be implemented when the patient next returns to the ED Frequent visitor lists Treatment contracts

40 The case 36y woman, presents with her typical migraine headache 12 days of migraine/ month Sumatriptan and ibuprofen usually give relief 2 ED visits/ month for severe migraine refractory to oral treatment Presents with 10/10 severe pain for 6 hours Doc, just give me my Demerol

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