Migraine and Other Causes of Headache,☆☆,

From the First International Symposium on Pain Research in Emergency Medicine, Montreal, October 1994.
https://doi.org/10.1016/S0196-0644(96)70228-7Get rights and content

Abstract

[Spence J: Migraine and other causes of headache. Ann Emerg Med April 1996;27:448-450.]

Section snippets

INTRODUCTION

Most emergency department-based headache research focuses on medication efficacy and does not employ standardized methodology that would allow for direct comparison among study groups and metaanalyses of trial data. This section discusses the unique characteristics of headache patients presenting to the ED and the methodologic issues of conducting headache research in the emergency medical setting.

UNIQUE ASPECTS OF THE ED HEADACHE POPULATION

More than 90% of people in the United States experience a headache during a given 1-year period.1 Most treat themselves with over-the-counter medications.2, 3, 4 An estimated 1.7% to 2.5% of patient visits to the ED are for complaint of headache.5 A Canadian survey found that approximately 14% of patients with migraine and 8% of patient with tension headaches presented to an ED for treatment.6 The patient population presenting to the ED may be different from the population treated by family

CLASSIFICATION OF HEADACHE

One problem in the selection of patients for drug trials is the definition of migraine and headache. The 1988 International Headache Society (IHS) document, Classification and Diagnostic Criteria for Headache Disorders, Cranial Neuralgias and Facial Pain,10 provides a headache classification system for research purposes. Several population-based studies have demonstrated the utility of this classification system.11, 12, 13 Some investigators, however, have proposed that headaches are not

USE OF PLACEBOS

Tfelt-Hansen and Olesen18 wrote that the efficacy of a drug in the treatment of migraine attacks can be definitively established only in double-blind trials and that placebo should be included in most cases. Although the placebo effect in migraine is high, it is difficult to evaluate the magnitude of the response because headaches are self limiting and symptoms are usually not maximal at the time of drug intake. The ethical propriety of using a placebo when alternative medications of

PAIN SCALES IN HEADACHE RESEARCH

Headache studies performed in the emergency setting have typically focused on relief of pain and associated symptoms, the most prominent being nausea and vomiting. The pain scales most commonly used are verbal rating scales, numeric rating scales, and visual analog scales that measure headache intensity and relief. Unidimensional scales often do not reflect the resulting level of dysfunction.20 They have no prognostic value for return of symptoms or attack frequency. Although these scales have

RELIEVING PAIN VERSUS ABORTING THE ATTACK

Rather than simply treating the pain and vegetative symptoms, the ultimate therapeutic goal is to abort the attack. Many migraine studies use pain and symptom relief at completion of the ED visit as the end point of the study. Follow-up at a later time (eg, 24 hours) is necessary to assess relapse and determine whether the therapy truly aborted the migraine attack.

MEASUREMENT OF OTHER OUTCOMES

Headache is more than just pain. Headache is often associated with comorbid conditions, such as nausea, vomiting, photophobia, and dysphoria, that in themselves may be disabling. Migraine has been shown to be a significant life burden in terms of lowered functional status and well-being.22 Therefore, other outcomes that may be measured include degree of functional impairment and interference with daily activities, return to normal function, and effect of medications on attack frequency and

STATISTICAL CONSIDERATIONS

The suitability of parametric tests for analysis of the results of analgesic trials has been questioned. Amery et al17, in an analysis of prophylactic drug studies in migraine, suggested that nonparametric tests be used unless the data show a gaussian distribution. Gawel et al.25 noted problems associated with the use of headache studies as the time and intensity of "peak" effect, used in other clinical pain models, may not be available. Furthermore, the sum of scores or "area under the curve"

References (25)

  • SH Thomas et al.

    Emergency department treatment of migraine, tension and mixed-type headache

    J Emerg Med

    (1994)
  • D Mayer

    Refusal of care and discharging "difficult" patients from the emergency department

    Ann Emerg Med

    (1990)
  • CW Barton

    Evaluation and treatment of headache patients in the emergency department: A survey

    Headache

    (1994)
  • RG Robinson

    Pain relief for headaches: Is self-medication a problem?

    Can Fam Physician

    (1993)
  • DD Celentano et al.

    Medication use and disability among migraineurs: A national probability sample survey

    Headache

    (1992)
  • LN Oates et al.

    Polypharmacy in a headache centre population

    Headache

    (1993)
  • J Edmeads et al.

    Impact of migraine and tension-type headache on life-style, consulting behaviour and medication use: A Canadian population survey

    Can J Neurol Sci

    (1993)
  • AM Rapoport et al.

    Emergency treatment of headache

    Neurology

    (1992)
  • HG Markley

    Chronic headache: Appropriate use of opiate analgesics

    Neurology

    (1994)
  • Headache Classification Committee of the International Headache Society

    Classification and diagnostic criteria for headache disorders, cranial neuralgias and facial pain

    Cephalalgia

    (1988)
  • AM Rapaport

    The diagnosis of migraine and tension type headache, then and now

    Neurology

    (1992)
  • KR Merikangas et al.

    Diagnostic criteria for migraine: A validity study

    Neurology

    (1994)
  • Cited by (5)

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      1998, Emergency Medicine Clinics of North America

    From the Division of Emergency Medicine, Department of Medicine, University of Toronto and St Michael's Hospital, Toronto, Ontario.

    ☆☆

    Address for reprints: Julie Spence, MD, Department of Emergency Medicine, Suite BG-13, Sunnybrook Health Science Center, 2075 Bayview Avenue, Toronto, Ontario, Canada M4N 3M5

    Reprint no. 47/1/72434

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