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Acute migraine in the Emergency Department: extending European principles of management

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Abstract

The World Health Organization (WHO) placed migraine 19th among all causes of disability (12th in women) measured in years of healthy life lost to disability (YLD). The importance of headache disorders, particularly of the primary forms, is established by their distribution worldwide, their duration (the majority being life-long conditions) and their imposition of both disability and life-style restrictions among large numbers of people. For these reasons, headache disorders should represent a public-health priority. In the Emergency Department (ED), as elsewhere, migraine is often under-diagnosed—and under-treated when it is diagnosed. The result is likely to be failure of treatment. Particular attention to diagnosis is needed in ED patients with acute headache, since there is a higher probability of secondary headache due to underlying pathologies. According to European principles of management, acute migraine treatment generally is stepwise. Of the two main steps, the first relies on symptomatic medication, preferably NSAIDs with or without antiemetics. The second step uses specific therapies, usually triptans. Modifications to routine practice are appropriate in the ED. Parenteral administration of symptomatic therapies is a preferred first choice, whilst immediate resort to triptans may be appropriate, and achieve better outcomes, in patients with severe headache and diagnostic confirmation of migraine.

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References

  1. Rasmussen BK (2001) Epidemiology of headache. Cephalalgia 21:774–777

    Article  PubMed  CAS  Google Scholar 

  2. Stovner LJ, Zwart JA, Hagen K, Terwindt GM, Pascual J (2006) Epidemiology of headache in Europe. Eur J Neurol 13:333–345

    Article  PubMed  CAS  Google Scholar 

  3. Stovner LJ, Hagen K, Jensen R, Katsarava Z, Lipton R, Scher A, Steiner T, Zwart JA (2007) The global burden of headache: a documentation of headache prevalence and disability worldwide. Cephalalgia 27:193–210

    Article  PubMed  Google Scholar 

  4. World Health Organization (2001) World Health Report 2001. WHO, Geneva

  5. Zwart JA, Dyb G, Hagen K, Svebak S, Holmen J (2003) Analgesic use: a predictor of chronic pain and medication overuse headache: the Head-HUNT Study. Neurology 61:160–164

    PubMed  Google Scholar 

  6. Colás R, Muñoz P, Temprano R, Gómez C, Pascual J (2004) Chronic daily headache with analgesic overuse: epidemiology and impact on quality of life. Neurology 62:1338–1342

    PubMed  Google Scholar 

  7. Martelletti P, Steiner TJ, Bertolote JM, Dua T, Saraceno B (2007) The definitive position of headache among the major public health challenges. An end to the slippery slope of disregard. J Headache Pain 8:149–151

    Article  PubMed  Google Scholar 

  8. Locker T, Mason S, Rigby A (2004) Headache management—are we doing enough? An observational study of patients presenting with headache to the Emergency Department. Emerg Med J 21:327–332

    Article  PubMed  CAS  Google Scholar 

  9. Morgenstern LB, Huber JC, Luna-Gonzales H, Saldin KR, Grotta JC, Shaw SG, Knudson L, Frankowski RF (2001) Headache in the Emergency Department. Headache 41:537–541

    Article  PubMed  CAS  Google Scholar 

  10. Stevenson RJ, Dutta D, MacWalter RS (1998) The management of acute headache in adults in an acute admissions unit. Scott Med J 43:173–176

    PubMed  CAS  Google Scholar 

  11. Ramirez-Lassepas M, Espinosa CE, Cicero JJ, Johnston KL, Cipolle RJ, Barber DL (1997) Predictors of intracranial pathologic findings in patients who seek emergency care because of headache. Arch Neurol 54:1506–1509

    PubMed  CAS  Google Scholar 

  12. Relja G, Granato A, Capozzoli F, Maggiore C, Catalan M, Pizzolato G, Zalukar W, Livia V, Gregorutti S, Zorzon M (2005) Nontraumatic headache in the Emergency Department: a survey in the province of Trieste. J Headache Pain 6:298–300

    Article  PubMed  Google Scholar 

  13. de Falco FA, Sterzi R, Toso V, Consoli D, Guidetti D, Provinciali L, Leone MA, Beghi E (2008) The neurologist in the Emergency Department. An Italian nationwide epidemiological survey. Neurol Sci 29:67–75

    Article  PubMed  Google Scholar 

  14. Locker TE, Thompson C, Rylance J, Mason SM (2006) The utility of clinical features in patients presenting with nontraumatic headache: an investigation of adult patients attending an Emergency Department. Headache 46:954–961

    Article  PubMed  Google Scholar 

  15. Scagni P, Pagliero R (2008) Headache in an Italian paediatric Emergency Department. J Headache Pain 9:83–87

    Article  PubMed  Google Scholar 

  16. Headache Classification Subcommittee of the International Headache Society (2004) The international classification of headache disorders, 2nd edition. Cephalalgia 24(suppl 1):1–160

    Google Scholar 

  17. Steiner TJ, Paemeleire K, Jensen R, Valade D, Savi L, Lainez MJ, Diener HC, Martelletti P, Couturier EG, on behalf of European Headache Federation and Lifting The Burden: The Global Campaign to Reduce the Burden of Headache Worldwide (2007) European principles of management of common headache disorders in primary care. J Headache Pain 8:S3–S47

    Article  PubMed  Google Scholar 

  18. Cohen AS, Matharu MS, Goadsby PJ (2007) Trigeminal autonomic cephalalgias: current and future treatments. Headache 47:969–980

    Article  PubMed  Google Scholar 

  19. Romano A, Cipriani V, Bozzao A (2006) Neuroradiology and headaches. J Headache Pain 7:422–432

    Article  PubMed  Google Scholar 

  20. van Gijn J, Rinkel GJ (2001) Subarachnoid haemorrhage: diagnosis, causes and management. Brain 124:249–278

    Article  PubMed  Google Scholar 

  21. Morgenstern LB, Luna-Gonzales H, Huber JC Jr, Wong SS, Uthman MO, Gurian JH, Castillo PR, Shaw SG, Frankowski RF, Grotta JC (1998) Worst headache and subarachnoid hemorrhage: prospective, modern computed tomography and spinal fluid analysis. Ann Emerg Med 32:297–304

    PubMed  CAS  Google Scholar 

  22. Perry JJ, Spacek A, Forbes M, Wells GA, Mortensen M, Symington C, Fortin N, Stiell IG (2008) Is the combination of negative computed tomography result and negative lumbar puncture result sufficient to rule out subarachnoid hemorrhage? Ann Emerg Med 51:707–713

    Article  PubMed  Google Scholar 

  23. Polmear A (2003) Sentinel headaches in aneurysmal subarachnoid haemorrhage: what is the true incidence? A systematic review. Cephalalgia 23:935–941

    Article  PubMed  CAS  Google Scholar 

  24. Edlow JA, Malek AM, Ogilvy CS (2008) Aneurysmal subarachnoid hemorrhage: update for emergency physicians. J Emerg Med 34:237–251

    Article  PubMed  Google Scholar 

  25. Mohr JP, Caplan LR, Melski JW, Goldstein RJ, Duncan GW, Kistler JP, Pessin MS, Bleich HL (1978) The Harvard Cooperative Stroke Registry: a prospective registry. Neurology 28:754–762

    PubMed  CAS  Google Scholar 

  26. Ferro JM, Melo TP, Oliveira V, Salgado AV, Crespo M, Canhão P, Pinto AN (1995) A multivariate study of headache associated with ischemic stroke. Headache 35:315–319

    Article  PubMed  CAS  Google Scholar 

  27. Melo TP, Pinto AN, Ferro JM (1996) Headache in intracerebral hematomas. Neurology 47:494–500

    PubMed  CAS  Google Scholar 

  28. Kotwica Z, Brzeziński J (1985) Chronic subdural hematoma presenting as spontaneous subarachnoid hemorrhage. Report of six cases. J Neurosurg 63:691–692

    PubMed  CAS  Google Scholar 

  29. Pekdemir M, Yilmaz S, Ersel M, Sarisoy HT (2008) A rare cause of headache: cerebral venous sinus thrombosis due to hyperthyroidism. Am J Emerg Med 26:383

    Article  PubMed  Google Scholar 

  30. Wall M (2008) Idiopathic intracranial hypertension (pseudotumor cerebri). Curr Neurol Neurosci Rep 8:87–93

    Article  PubMed  Google Scholar 

  31. Schievink WI, Maya MM, Moser F, Tourje J, Torbati S (2007) Frequency of spontaneous intracranial hypotension in the Emergency Department. J Headache Pain 8:325–328

    Article  PubMed  Google Scholar 

  32. Chaudhuri A, Martin PM, Kennedy PG, Andrew Seaton R, Portegies P, Bojar M, Steiner I, EFNS Task Force (2008) EFNS guideline on the management of community-acquired bacterial meningitis: report of an EFNS Task Force on acute bacterial meningitis in older children and adults. Eur J Neurol 15:649–659

    Article  PubMed  CAS  Google Scholar 

  33. Gerretsen P, Kern RZ (2007) Reversible cerebral vasoconstriction syndrome or primary angiitis of the central nervous system? Can J Neurol Sci 34:467–477

    PubMed  Google Scholar 

  34. Singhal AB, Bernstein RA (2005) Postpartum angiopathy and other cerebral vasoconstriction syndromes. Neurocrit Care 3:91–97

    Article  PubMed  Google Scholar 

  35. Reid RL, Quigley ME, Yen SS (1985) Pituitary apoplexy. A review. Arch Neurol 42:712–719

    PubMed  CAS  Google Scholar 

  36. Young WB, Silberstein SD (1997) Paroxysmal headache caused by colloid cyst of the third ventricle: case report and review of the literature. Headache 37:15–20

    Article  PubMed  CAS  Google Scholar 

  37. Cantini F, Niccoli L, Nannini C, Bertoni M, Salvarani C (2008) Diagnosis and treatment of giant cell arteritis. Drugs Aging 25:281–297

    Article  PubMed  CAS  Google Scholar 

  38. Tang-Wai DF, Phan TG, Wijdicks EF (2001) Hypertensive encephalopathy presenting with thunderclap headache. Headache 41:198–200

    Article  PubMed  CAS  Google Scholar 

  39. Silbert PL, Mokri B, Schievink WI (1995) Headache and neck pain in spontaneous internal carotid and vertebral artery dissections. Neurology 45:1517–1522

    PubMed  CAS  Google Scholar 

  40. Wang WW, Lin CS (2008) Headache angina. Am J Emerg Med 26:387.e1–387.e2

    Google Scholar 

  41. Tomasello F, Alafaci C, Angileri FF, Calisto A, Salpietro FM (2008) Clinical presentation of trigeminal neuralgia and the rationale of microvascular decompression. Neurol Sci 29:S191–S195

    Article  PubMed  Google Scholar 

  42. Maizels M (2001) Headache evaluation and treatment by primary care physicians in an Emergency Department in the era of triptans. Arch Intern Med 161:1969–1973

    Article  PubMed  CAS  Google Scholar 

  43. Gupta MX, Silberstein SD, Young WB, Hopkins M, Lopez BL, Samsa GP (2007) Less is not more: underutilization of headache medications in a University Hospital Emergency Department. Headache 47:1125–1133

    Article  PubMed  Google Scholar 

  44. Lange R, Schwarz JA, Hohn M (2000) Acetylsalicylic acid effervescent 1, 000 mg (Aspirin®) in acute migraine attacks; a multicentre, randomized, double-blind, single-dose, placebo-controlled parallel group study. Cephalalgia 20:663–667

    Article  PubMed  CAS  Google Scholar 

  45. MacGregor AE, Dowson A, Davies PTG (2002) Mouth-dispersible aspirin in the treatment of migraine: a placebo-controlled study. Headache 42:249–255

    Article  PubMed  Google Scholar 

  46. Diener HC, Eikerman A, Gessner U et al (2004) Efficacy of 1, 000 mg effervescent acetylsalicylic acid and sumatriptan in treating associated migraine symptoms. Eur Neurol 52:50–56

    Article  PubMed  CAS  Google Scholar 

  47. The EMSASI Study Group: Diener HC, Bussone G, de Liano H et al. (2004) Placebo-controlled comparison of effervescent acetylsalicylic acid, sumatriptan and ibuprofen in the treatment of migraine attacks. Cephalalgia 24:947–954

    Google Scholar 

  48. Lipton RB, Goldstein J, Baggish JS, Yataco AR, Sorrentino JV, Quiring JN (2005) Aspirin is efficacious for the treatment of acute migraine. Headache 45:283–292

    Article  PubMed  Google Scholar 

  49. Lampl C, Voelker M, Diener H-C (2007) Efficacy and safety of 1000 mg effervescent aspirin: individual patient data meta-analysis of three trials in migraine headache and migraine accompanying symptoms. J Neurol 254:705–712

    Article  PubMed  CAS  Google Scholar 

  50. Codispoti JR, Prior MJ, Min Fu MS, Harte CM, Nelson EB (2001) Efficacy of nonprescription doses of ibuprofen for treating migraine headache. A randomized controlled trial. Headache 41:665–679

    Article  PubMed  CAS  Google Scholar 

  51. Diclofenac-K/Sumatriptan Migraine Study Group (1999) Acute treatment of migraine attacks: efficacy and safety of a nonsteroidal anti-inflammatory drug, diclofenac potassium, in comparison to oral sumatriptan and placebo. Cephalalgia 19:232–240

    Article  Google Scholar 

  52. Tfelt-Hansen P, De Vries P, Saxena PR (2000) Triptans in migraine: a comparative review of pharmacology, pharmacokinetics and efficacy. Drugs 60:1259–1287

    Article  PubMed  CAS  Google Scholar 

  53. Pfaffenrath V, Cunin G, Sjonell G, Prendergast S (1998) Efficacy and safety of sumatriptan tablets (25 mg, 50 mg and 100 mg) in the acute treatment of migraine: defining the optimum doses of oral sumatriptan. Headache 38:184–190

    Article  PubMed  CAS  Google Scholar 

  54. Salonen R, Ashford E, Dählof C, Dawson R, Gilhus NE, Lüben V et al (1994) Intranasal sumatriptan for the acute treatment of migraine. J Neurol 241:463–469

    Article  PubMed  CAS  Google Scholar 

  55. Chen LC, Ashcroft DM (2008) Meta-analysis of the efficacy and safety of zolmitriptan in the acute treatment of migraine. Headache 48:236–247

    PubMed  Google Scholar 

  56. Rapoport AM, Bigal ME, Tepper SJ, Sheftell FD (2004) Zolmitriptan (Zomig). Expert Rev Neurother 4:33–41

    Article  PubMed  CAS  Google Scholar 

  57. Krymchantowski AV, Bigal ME (2005) Rizatriptan in migraine. Expert Rev Neurother 5:597–603

    Article  PubMed  CAS  Google Scholar 

  58. Mathew NT, Asgharnejad M, Peykamian M, Laurenza A (1997) Naratriptan is effective and well tolerated in the acute treatment of migraine: results of a double-blind, placebo-controlled, crossover study. Neurology 49:1485–1490

    PubMed  CAS  Google Scholar 

  59. Dodick DW (2003) A review of the clinical efficacy and tolerability of almotriptan in acute migraine. Expert Opin Pharmacother 4:1157–1163

    Article  PubMed  CAS  Google Scholar 

  60. Dowson AJ (2004) Oral almotriptan: practical uses in the acute treatment of migraine. Expert Rev Neurother 4:339–348

    Article  PubMed  CAS  Google Scholar 

  61. Stark R, Dahlof C, Haughie S, Hettiarachchi J (2002) Efficacy, safety and tolerability of oral eletriptan in the acute treatment of migraine: results of a phase III, multicentre, placebo-controlled study across three attacks. Cephalalgia 22:23–32

    Article  PubMed  CAS  Google Scholar 

  62. Diener HC (2005) Eletriptan in migraine. Expert Rev Neurother 5:43–53

    Article  PubMed  CAS  Google Scholar 

  63. Ryan R, Géraud G, Goldstein J, Cady R, Keywood C (2002) Clinical efficacy of frovatriptan: placebo-controlled studies. Headache 42(suppl. 2):S84–S92

    Article  PubMed  Google Scholar 

  64. Géraud G, Spierings ELH, Keywood C (2002) Tolerability and safety of frovatriptan with short- and long-term use for treatment of migraine and in comparison with sumatriptan. Headache 42(suppl 2):S93–S99

    Article  PubMed  Google Scholar 

  65. Tfelt-Hansen P (2008) Triptans vs other drugs for acute migraine. Are there differences in efficacy? A comment. Headache 48:601–605

    Article  PubMed  Google Scholar 

  66. Steiner TJ (2008) Triptans vs other drugs for acute migraine [letter to editor]. Headache 48 (in press)

  67. Diener H-C (1999) Efficacy and safety of intravenous acetylsalicylic acid lysinate compared to subcutaneous sumatriptan and parenteral placebo in the acute treatment of migraine. A double-blind, double-dummy, randomized, multicenter, parallel group study. The ASASUMAMIG Study Group. Cephalalgia 19:581–588

    Article  PubMed  CAS  Google Scholar 

  68. Engindeniz Z, Demircan C, Karli N, Armagan E, Bulut M, Aydin T, Zarifoglu M (2005) Intramuscular tramadol vs. diclofenac sodium for the treatment of acute migraine attacks in emergency department: a prospective, randomised, double-blind study. J Headache Pain 6:143–148

    Article  PubMed  CAS  Google Scholar 

  69. The Subcutaneous Sumatriptan International Study Group (1991) Treatment of migraine attacks with sumatriptan. N Engl J Med 325:316–321

    Google Scholar 

  70. Tfelt-Hansen P (2007) Parenteral vs. oral sumatriptan and naratriptan: plasma levels and efficacy in migraine. A comment. J Headache Pain 8:273–276

    Article  PubMed  CAS  Google Scholar 

  71. Akpunonu BE, Mutgi AB, Federman DJ, Volinsky FG, Brickman K, Davis RL, Gilbert C, Asgharnejad M (1995) Subcutaneous sumatriptan for treatment of acute migraine in patients admitted to the emergency department: a multicenter study. Ann Emerg Med 25:464–469

    Article  PubMed  CAS  Google Scholar 

  72. Blumenthal HJ, Weisz MA, Kelly KM, Mayer RL, Blonsky J (2003) Treatment of primary headache in the Emergency Department. Headache 43:26–31

    Article  Google Scholar 

  73. Dodick DW, Papademetriou V (2004) Cardiovascular safety of triptans. Cephalalgia 24:513–514

    Article  PubMed  CAS  Google Scholar 

  74. Houghton LA, Foster J, Whorwell PJ, Morris J, Fowler P (1994) Is chest pain after sumatriptan oesophageal in origin? Lancet 344:985–986

    Article  PubMed  CAS  Google Scholar 

  75. Boska MD, Welch KM, Schultz L, Nelson J (2000) Effects of the anti-migraine drug sumatriptan on muscle energy metabolism: relationship to side-effects. Cephalalgia 20:39–44

    Article  PubMed  CAS  Google Scholar 

  76. MacLean MR, Clayton RA, Templeton AG, Morecroft I (1996) Evidence for 5-HT-1-like receptor-mediated vasoconstriction human pulmonary artery. Br J Pharmacol 119:277–282

    PubMed  CAS  Google Scholar 

  77. Sarkar S, Aziz Q, Woolf CJ, Hobson AR, Thompson DG (2000) Contribution of central sensitization to the development of non-cardiac chest pain. Lancet 356:1154–1159

    Article  PubMed  CAS  Google Scholar 

  78. Goldstein JA, Massey KD, Kirby S, Gibson M, Hettiarachchi J, Rankin AJ, Jackson NC (2004) Effect of high-dose intravenous eletriptan on coronary artery diameter. Cephalalgia 24:515–521

    Article  PubMed  CAS  Google Scholar 

  79. Vinson D (2002) Treatment patterns of isolated benign headache in US Emergency Departments. Ann Emerg Med 39:215–222

    Article  PubMed  Google Scholar 

  80. Friedman BW, Kapoor A, Friedman MS, Hochberg ML, Rowe BH (2008) The relative efficacy of meperidine for the treatment of acute migraine: a meta-analysis of randomized controlled trials. Ann Emerg Med (in press)

  81. Alemdar M, Pekdemir M, Selekler HM (2007) Single-dose intravenous tramadol for acute migraine pain in adults: a single-blind, prospective, randomized, placebo-controlled clinical trial. Clin Ther 29:1441–1447

    Article  PubMed  CAS  Google Scholar 

  82. Martelletti P, Haimanot RT, Láinez MJ, Rapoport AM, Ravishankar K, Sakai F, Silberstein SD, Vincent M, Steiner TJ (2005) The Global Campaign (GC) to Reduce the Burden of Headache Worldwide. The International Team for Specialist Education (ITSE). J Headache Pain 6:261–263

    Article  PubMed  Google Scholar 

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Acknowledgments

Special thanks go to Caterina Panetta for her help with the English language in the first draft of the manuscript.

Conflict of interest statement

The authors declare that they have no conflict of interest related to the publication of this manuscript.

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Authors and Affiliations

  1. Department of Medical Sciences, Internal Medicine, Regional Referral Headache Centre, 2nd School of Medicine, Sapienza University of Rome, Sant’Andrea Hospital, Via di Grottarossa 1035, 00189, Rome, Italy

    Paolo Martelletti & Ivano Farinelli

  2. Division of Neuroscience and Mental Health, Imperial College London, London, UK

    Timothy J. Steiner

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  1. Paolo Martelletti
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  2. Ivano Farinelli
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  3. Timothy J. Steiner
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on behalf of the Working Group for Specialist Education, WHO’s Global Campaign to Reduce the Burden of Headache Worldwide (Lifting The Burden)

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Correspondence to Paolo Martelletti.

Additional information

Paolo Martelletti is Chairman of Working Group for Specialist Education, Lifting The Burden.

Timothy J. Steiner is Chairman of Global Campaign Committee, Lifting The Burden.

Lifting The Burden: http://www.who.int/mental_health/neurology/headache/en/

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Martelletti, P., Farinelli, I., Steiner, T.J. et al. Acute migraine in the Emergency Department: extending European principles of management. Intern Emerg Med 3 (Suppl 1), 17–24 (2008). https://doi.org/10.1007/s11739-008-0188-1

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