Ambient air pollution and daily emergency department visits for headache in Ottawa, Canada

Background.— No extensive studies exist on the relation between ambient air pollution and health outcomes such as migraine or headache. From other side, existing publications indicated that air pollutants can trigger migraine or headache.
Objective.— To examine associations between emergency department (ED) visits for headache and environmental conditions: ambient air pollution concentrations adjusted for weather factors (atmospheric pressure, temperature, and relative humidity).
Design and Methods.— This is a time-series study of 8012 ED visits for headache (International Classification for Diseases ninth revision: 784) recorded at an Ottawa hospital between 1992 and 2000. The generalized linear mixed models technique is used to model relation between daily counts of ED visits for headache and ambient air pollutants (gases: sulphur dioxide [SO₂], nitrogen dioxide [NO₂], carbon monoxide [CO]). The counts of visits for all patients, male and female patients, are analyzed separately.
Results.— The percentage increase in daily ED visits for headache was 4.2% (95% CI: 0.2, 6.4) and 4.9% (95% CI: 1.2, 8.8) for 1-day and 2-day lagged exposure to SO₂ for an increase in the interquartile range (IQR, IQR = 3.9 ppb). The positive statistically significant associations were also observed for exposure to NO₂ and CO for all and male ED visits for headache.
Conclusions.— Presented findings provide support for the hypothesis that ED visits for headache are related to ambient air pollution.     

Impact of a group-based model of disease management for headache

OBJECTIVES: To assess the impact of a group-based model of disease management for patients with headache. BACKGROUND: Despite advances in the acute and preventive treatment of migraine, many patients with headache remain misdiagnosed and undertreated. Models of care that incorporate principles of disease management may improve headache care. DESIGN AND METHODS: This was a prospective, open-label, observational study. Patients with headache were referred by physicians or identified from emergency department records. Patients attended a group session led by a registered nurse practitioner, and later had follow-up consultation. Charts and computer records were reviewed to document triptan costs and headache-related visits for 6 months before and after the intervention. Changes in headache frequency and severity were assessed. RESULTS: Triptan costs for 264 patients and chart review for 250 were available. Six-month triptan costs increased $5423 US dollars(19%), headache-related visits were reduced by 32%, and headache-related emergency department visits were reduced by 49%. Severe headache frequency was reduced in 62 (86%) of 72 patients who initially had severe headaches more than 2 days per week. Patients identified by emergency department screening accounted for 21% of the study group, 31% of the baseline triptan costs, and 46% of the baseline visits. For the entire study group, reduced visits yielded a net savings of $18,757 US dollars despite increased triptan costs. CONCLUSIONS: Implementation of this group-based model produced a reduction in emergency department and clinic visits, significant clinical improvement, a small increase in pharmacy costs, and overall cost reduction. The greatest improvement in each outcome measure was seen in patients most severely afflicted at baseline. Our results suggest that the principles of disease management may be applied effectively to a headache population, with a positive financial impact on a managed care organization.     

Droperidol for acute migraine headache.

The use of intramuscular droperidol to treat acute migraine headache has not been previously reported in the emergency medicine literature. It is a promising therapy for migraine. The authors performed a pilot review of all patients receiving droperidol for migraine in our emergency department (ED) to evaluate its efficacy. We used a retrospective case series, in a suburban ED with an annual patient census of 48,000. All patients with a discharge diagnosis of migraine headache who were treated with i.m. droperidol during a consecutive 5-month period in our ED were identified. All patients received droperidol 2.5 mg intramuscular. As per ED protocol, their clinical progress was closely followed and documented at 30 minutes after drug administration (t30). Demographic and clinical variables were recorded on a standardized, closed-question, data collection instrument. The primary outcome measurement was relief of symptoms at t30 to the point that the patient felt well enough to go home without further ED intervention (symptomatic relief). Thirty-seven patients were treated (84% female), with an ED diagnosis of acute migraine with droperidol during the study period. The mean age was 36 +/- 12 years. Analgesics had been used within 24 hours before ED presentation by 62% of patients. At t30, 30 (81%) patients had symptomatic relief, 2 (5%) felt partial relief but required rescue medication, and 5 (14%) had no relief of symptoms. Drowsiness (14%) and mild akathisia (8%) were the only adverse reactions observed following drug administration. Droperidol 2.5 mg intramuscular may be a safe and effective therapy for the ED management of acute migraine headache. Randomized, controlled trials are warranted to further validate the findings of this preliminary study.     

The epidemiology of migraine: a retrospective study in Italian emergency departments

This study was conducted to measure the frequency of contact with emergency departments in Italy because of migraine, and to compare the initial diagnosi s of headache with the diagnosis after application of the International Headache Society (IHS) criteria. A retrospective observational method was used, consisting of an analysis of the records of patients admitted to nine Italian emergency departments during different 4-month periods in 1994. Comparison of the initial diagnosis with the diagnosis after application of the IHS diagnostic criteria was performed. More than 31 million emergency department contacts were reported in Italy during 1994. In the same year, 543 630 patients visited the nine emergency departments enrolled in the study, with 169 569 of these contacts occurring in the 4-month period analyzed in the study. We excluded from the analysis all cases of secondary headache fully recognized at the emergency department admission (ie, traumas, intracranial pathology, systemic diseases). The total number of patients included in our analysis was 1043 (0.6%). The 934 patients who could be fully evaluated were initially classified as having migraine; cluster headache; headache not otherwise specified; or diagnosed in the emergency department as suffering from headache, but reclassified by other departments as suffering from a different disease. After retrospective application of the IHS classification, the diagnostic distribution was modified, revealing that 18% of patients with migraine and 5% with cluster headaches had previously been classified as having headache not otherwise specified; a further 6% of cases with migraine and 0.4% of patients with cluster headache had previously been classified as having secondary headaches. The diagnosis of headache not otherwise specified was made with notable frequency, indicating the limits of emergency department logs and the difficulty in carrying out a retrospective analysis and reassessment of diagnosis. The majority (88%) of patients assessed had not taken drugs for headache in the 48 hours before the emergency department contact, suggesting that in Italy emergency departments are used instead of a visit to the general practitioner. Nonsteroidal anti-inflammatory drugs were the most frequently prescribed drugs in the emergency departments for this group of diagnoses. The research revealed, on the one hand, that headache is a numerically significant phenomenon in the emergency department setting and, on the other, the need to apply prospective designs to this kind of survey.     

Oral Narcotic Protocol to Reduce Narcotic Injections in Refractory Migraine Patients

Refractory headache patients who require narcotic injections for acute attacks frequently utilize health care facilities. The experience is often unpleasant and costly to the patient and health care system.
We have developed an oral narcotic protocol for home administration. The patient starts with an antiemetic suppository, followed in 30 minutes by oral metoclopramide. After controlling nausea and vomiting, the patient administers a high dose of oral narcotic plus a hypnotic. The dosing of the narcotic analgesics incorporates seldom-used, but well-published pharmacokinetics. This protocol allows the patient to successfully treat a severe headache without using a health care facility.
Eleven patients in our practice were prescribed the oral narcotic protocol. Their need for narcotic injections at our office or emergency department was monitored for up to 1 year before and after the start of the protocol. Combined office visits were reduced from 81 to 53 (34.6%) and emergency department visits from 47 to 26 (44.7%). An annual cost savings of $1960 for office visits and $3024 for emergency department visits was realized. This was offset by an oral narcotic protocol medication cost of only $392. This treatment method has been well accepted by patients and has proven to be a safe and cost-effective approach to treating refractory migraine patients.     

Steroids for Migraine Headaches: A Randomized Double-Blind, Two-Armed, Placebo-Controlled Trial

Background: Recurrence of migraine headache after treatment in the emergency department (ED) is common. Conflicting evidence exists regarding the utility of steroids in preventing migraine headache recurrence at 24–48 h. Objective: To determine if steroids decrease the headache recurrence in patients treated for migraine headaches in the ED. Methods: Double-blind placebo-controlled, two-tailed randomized trial. Patients aged >17 years with a moderately severe migraine headache diagnosed by treating Emergency Physician were approached for participation. Enrollees received either dexamethasone (10 mg i.v.) if intravenous access was utilized or prednisone (40 mg by mouth × 2 days) if no intravenous access was obtained. Each medication was matched with an identical-appearing placebo. Patients were contacted 24–72 h after the ED visit to assess headache recurrence. Results: A total of 181 patients were enrolled. Eight were lost to follow-up, 6 in the dexamethasone group and 2 in the prednisone arm. Participants had a mean age of 37 years (±10 years), with 86% female. Eighty-six percent met the International Headache Society Criteria for migraine headache. Of the 173 patients with completed follow-up, 20/91 (22%) (95% confidence interval [CI] 13.5–30.5) in the steroid arm and 26/82 (32%) (95% CI 21.9–42.1) in the placebo arm had recurrent headaches (p = 0.21). Conclusion: We did not find a statistically significant decrease in headache recurrence in patients treated with steroids for migraine headaches.     

Headache in an Italian pediatric emergency department

The objective of this study was to assess epidemiology, diagnostic work-up, treatment and follow-up of children presenting to emergency department (ED) with headache. Records of visits for non-traumatic headache to the ED of a pediatric hospital over a period of 12 months were retrospectively reviewed. Headache center charts were analyzed one year after. Five-hundred and fifty patients (1% of all ED visits) were included. Spectrum of diagnoses was: primary headache (56.7%), with 9.6% of migraine; secondary headache (42%); unclassified headache (1.3%). Viral illnesses accounted for 90.5% of secondary headaches. A serious disorder was found in 4% of patients. Forty-four patients (8%) underwent neuroimaging studies, with 25% of abnormal findings. Only 223 patients (40.5%) received pharmacological treatment. On discharge, 212 patients (38.5%) were referred to headache center and 114 (20.7% of all patients) attended it. ED diagnosis was confirmed in 74.6% of cases. Most of ED repeated visits (82.6%) occurred in patients not referred to headache center at discharge from first ED visit. The most frequent diagnosis was primary headache; viral illnesses represented the majority of secondary headaches. Underlying serious disorders were associated with neurological signs, limiting the need of diagnostic investigations. Well structured prospective studies are needed to evaluate appropriate diagnostic tools, as well as correct therapeutic approach of pediatric headache in emergency. Collaboration with headache center might limit repeated visits and provide a correct diagnostic definition.     

Use of the Emergency Department for Severe Headache. A Population-Based Study

Background.— Although headache is a common emergency department (ED) chief complaint, the role of the ED in the management of primary headache disorders has rarely been assessed from a population perspective. We determined frequency of ED use and risk factors for use among patients suffering severe headache. Methods.— As part of the American Migraine Prevalence and Prevention study, a validated self‐administered questionnaire was mailed to 24,000 severe headache sufferers, who were randomly drawn from a larger sample constructed to be sociodemographically representative of the US population. Participants were asked a series of questions on headache management, healthcare system use, sociodemographic features, and number of ED visits for management of headache in the previous 12 months. In keeping with the work of others, “frequent” ED use was defined as a particpant's report of 4 or more visits to the ED for treatment of a headache in the previous 12 months. Headaches were categorized into specific diagnoses using a validated methodology. Results.— Of 24,000 surveys, 18,514 were returned, and 13,451 (56%) provided complete data on ED use. Sociodemographic characteristics did not differ substantially between responders and nonresponders. Among the 13,451 responders, over the course of the previous year, 12,592 (94%) did not visit the ED at all, 415 (3%) visited the ED once, and 444 (3%) visited the ED more than once. Patients with severe episodic tension‐type headache were less likely to use the ED than patients with severe episodic migraine (OR 0.4 [95% CI: 0.3, 0.6]). Frequent ED use was reported by 1% of the total sample or 19% (95% CI: 17%, 22%) of subjects who used the ED in the previous year, although frequent users accounted for 51% (95% CI: 49%, 53%) of all ED visits. Predictors of ED use included markers of disease severity, elevated depression scores, low socioeconomic status, and a predilection for ED use for conditions other than headache. Conclusions.— Most individuals suffering severe headaches do not use the ED over the course of a single year. The majority of ED visits for severe headache are accounted for by a small subset of all ED users. Increasing disease severity and depression are the most readily addressable factors associated with ED use.     

Predicting the number of headache visits by type of patient seen in family practice

OBJECTIVES: To examine the number of visits involving a headache diagnosis among patients to four family practice sites between July 1, 1995 and December 31, 1998. BACKGROUND: Although the majority of care-seeking headache sufferers are seen in the primary care setting, few studies have attempted to document the relationship between type of headache as diagnosed by the family practice physician, and number of the patient's headache visits. Design.-Secondary analysis of administrative claims data. METHODS: We compared headache visits per person-year by the age and sex of patient among patients classified according to headache diagnosis received: tension-type only; headache not otherwise specified (NOS) only; migraine only; tension-type and headache NOS; tension-type and migraine; headache NOS and migraine, and migraine, tension-type, and headache NOS. Patients with an International Classification of Diseases (version 9) code of 346 were considered to have a diagnosis of migraine, with 307.81 representing tension-type headache, and 784 representing headache NOS. Age was measured from date of birth to initial visit in the study period and patients were subdivided into 5-year age groups. Person-years "at risk" for each diagnosis was measured from the time of initial visit during the study period to December 31, 1998. RESULTS: We examined data from 4112 patients who made 9322 visits with a headache diagnosis. We found that the average number of visits per person-year increases as the number of different types of headache diagnoses increased and were greatest for patients having migraine as opposed to headache NOS and tension-type diagnoses. CONCLUSIONS: Headache type is an important predictor of the number of office visits involving a headache diagnosis in family practice. Patients with multiple headache diagnoses have more visits. Patients with combinations of headache diagnoses involving migraine are the most frequent visitors.     

Examining the utility of in-clinic "rescue" therapy for acute migraine

Background.— Management options currently are limited for patients with acute migraine whose symptoms prove refractory to self‐administered therapy. Objective.— To evaluate the clinical utility and cost‐effectiveness of a management program offering in‐clinic “rescue” treatment for patients with acute migraine. Methods.— Two hundred consecutive migraine patients presenting to a university‐based headache clinic were randomized to receive either optimal self‐administered medical therapy for acute migraine (“standard therapy”) or similar therapy plus the option of in‐clinic parenteral drug administration should self‐administered therapy prove ineffective (“rescue therapy”). Patients randomized to the latter group were restricted to a maximum of 2 “rescue visits” per month, and all patients were followed for one year. Patients “rescued” in clinic were contacted by telephone 24 hours following treatment to evaluate their treatment response. The primary analysis involved a comparison of the number of emergency department (ED) visits for headache recorded within each group over the one‐year period of study. For all ED visits in the rescue group and for a randomly selected and equal number of ED visits within the standard group, the direct costs associated with those visits were assessed, and the direct costs of all in‐clinic rescue visits also were recorded and analyzed. Results.— The 2 groups studied were similar in terms of age, gender ratio, migraine subtype, migraine‐related disability status at baseline and type/extent of medical insurance coverage. Over the one‐year study period, the rescue group recorded 423 in‐clinic rescue visits and reported 27 ED visits for headache treatment. The standard therapy group reported 73 ED visits (27 vs 73 visits; P < .01). The total direct costs associated with ED visits were $45,330 for the rescue group (mean $1690 per ED visit) and (by extrapolation from the sample selected) $147,971 for the standard therapy group (mean $2027 per ED visit). The total direct cost of the 423 “rescue visits” was $33,647 (mean $80 per visit). In 79% of the 423 rescue encounters, the patients involved reported no residual functional disability 24 hours following treatment. Of those in the rescue group who sought in‐clinic rescue, 89% reported themselves “very satisfied” with such management. Conclusion.— Providing the alternative of in‐clinic “rescue” for acute migraine refractory to self‐administered therapy offers an attractive alternative for patients and appears to substantially lower use of an ED for headache treatment and the cost associated with that use.     

Air pollution and daily ED visits for migraine and headache in Edmonton,Canada

Background

A variety of environmental factors have been identified as possible triggers for migraine and other headache syndromes.

Objective

We analyzed associations between air pollution and emergency department (ED) visits for migraine and headache.

Methods

Analysis was based on 56 241 ED visits for migraine and 48 022 ED visits for headache to Edmonton hospitals between 1992 and 2002. A Poisson model of counts hierarchically clustered by day of week, month, and year was applied using generalized linear mixed models. Temperature and relative humidity were included as covariates.

Results

Females accounted for 78.5% of migraine visits and 56.3% of headache visits. An interquartile range (IQR) increase (6.2 μg/m³) in daily average particulate matter of median aerodynamic diameter less than 2.5 μm (PM_2.5) was associated with increases in visits of 3.3% for migraine (95% confidence interval [CI]: 0.6-6.0), lagged 2 days, and 3.4% for headache (95% CI: 0.3-6.6), lagged 0 days, among females in the cold season (October-March). PM_2.5 was also associated with cold season migraine visits among females at lag 0 and 1 day (P < .1). In the warm period (April-September), a 2.3-ppb IQR increase in sulfur dioxide was associated with a 2.5% increase in migraine visits (95% CI: 0.3-4.6) among females, whereas a 12.8-ppb IQR increment in nitrogen dioxide was associated with a 6.8% increase in headache visits (95% CI: 1.5-12.5) for males.

Conclusions

Findings provide preliminary evidence of an association between air pollution and ED visits for migraine and nonspecific headache. Findings were most consistent for particulate matter.     

A possible role of ID-Migraine™ in the emergency department: study of an emergency department out-patient population

Headache symptoms account for 1–3% of admissions to an emergency department (ED). Most patients affected by a primary headache (PH) have migraine, although they are often misdiagnosed as 'headache not otherwise specified'. We investigated the possibility of using ID-Migraine (ID-M) to improve migraine recognition in the ED setting. We planned a pilot study involving ED out-patients with a diagnosis of PH. Diagnoses of a blinded headache expert were subsequently matched with the ID-M results. We tested ID-M on 230 patients (199 PH, 31 secondary headaches). Considering only PH, ID-M exhibited a sensitivity of 0.94 and specificity of 0.83 with a positive predictive value (PPV) of 0.99. The ID-M is a simple migraine screener with high sensitivity, high specificity and high PPV, even in an ED-derived population. Methodical use of this tool in an ED setting may, once a secondary headache has been excluded, lead to rapid diagnosis of migraine.     

Rapid and sensitive paradigm for screening patients with headache in primary care settings

OBJECTIVE: To determine the sensitivity and specificity of a brief headache screening paradigm for primary care clinicians. BACKGROUND: Migraine and drug rebound headache are disabling primary headache disorders. Both are underdiagnosed and undertreated. A method for rapid screening of migraine, drug rebound headache, and other daily headache syndromes would be useful. The Brief Headache Screen uses 3 questions-the frequency of severe (disabling) headache, other (mild) headache, and use of symptomatic medication-to generate diagnoses. METHODS: The Brief Headache Screen was evaluated in an emergency department, a family practice department, and a referral headache clinic. Diagnoses from the Brief Headache Screen were compared to diagnoses of trained researchers and headache specialists. RESULTS: Three hundred ninety-nine patients were screened and interviewed. The criterion of episodic severe (disabling) headache correctly identified migraine in 136 (93%) of 146 patients with episodic migraine and 154 (78%) of 197 patients with chronic migraine, with a specificity for any migraine (episodic or chronic) of 32 (63%) of 51. The inclusion of episodic or daily severe headache identified migraine in 100% of patients with chronic migraine. Only 6 (1.7%) of 343 patients with migraine were not identified by severe (disabling) headache. The combination of severe and mild headache frequency was sensitive to daily headache syndromes in 218 (94%) of 232 patients with a specificity of 87 (54%) of 162. Medication overuse was correctly identified in 146 (86%) of 169 patients with a specificity of 22 (79%) of 28. CONCLUSIONS: The frequency of severe (disabling) and mild headaches and use of symptomatic medications, rapidly and sensitively screens for migraine, daily headache syndromes, and medication overuse. The use of this paradigm in primary care settings may improve the recognition of these important headache syndromes.     

Pediatric Migraine: Abortive Management in the Emergency Department

Studies suggest that headache accounts for approximately 1% of pediatric emergency department (ED) visits. ED physicians must distinguish between primary headaches, such as a tension or migraine, and secondary headaches caused by systemic disease including neoplasm, infection, or intracranial hemorrhage. A recent study found that 40% of children presenting to the ED with headache were diagnosed with a primary headache, and 75% of these were migraine. Once the diagnosis of migraine has been made, the ED physician is faced with the challenge of determining appropriate abortive treatment. This review summarizes the most recent literature on pediatric migraine with an emphasis on diagnosis and abortive treatment in the ED.     

Air pollution and daily emergency department visits for headache in Montreal, Canada

BACKGROUND: Many studies have indicated that weather can trigger headache. Here we propose a new methodological approach to assess the relationship between weather, ambient air pollution, and emergency department (ED) visits for this condition. OBJECTIVE: To examine the associations between ED visits for headache and selected meteorological and air pollution factors. DESIGN AND METHODS: A hierarchical clusters design was used to study 10,497 ED visits for headache (ICD-9: 784) that occurred at a Montreal hospital between 1997 and 2002. The generalized linear mixed models technique was applied to create Poisson models for the clustered counts of visits for headache. RESULTS: Statistically significant positive associations were observed between the number of ED visits for headache and the atmospheric pressure for all and for female visits for 1-day and 2-day lagged exposures. The percentage increase in daily ED female visits was 4.1% (95% CI: 2.0, 6.2), 3.4% (95% CI: 1.4, 5.6), and 2.2% (95% CI: 1.4, 5.6) for current day, 1-day and 2-day lagged exposure to SO(2), respectively, for an increase of an interquartile range (IQR) of 2.4 ppb. The percentage increase was also statistically significant for current day and 1-day lagged exposure to NO(2) and CO for all and for female visits. CONCLUSIONS: Presented findings provide support for the hypothesis that ED visits for headache are correlated to weather conditions and ambient air pollution - to atmospheric pressure and exposure to SO(2), NO(2), CO, and PM(2.5). An increase in levels of these factors is associated with an increase in the number of ED visits for headache.