More than one-quarter of initial emergency department (ED) visits for migraine are followed by headache revisits in fewer than six months, according to a retrospective study of New York City hospitals. Reporting in the March issue of Headache, Mia T. Minen, MD, MPH, and colleagues found that among patients discharged from the ED with a diagnosis of migraine, 12.5% revisit the same ED for headache more than once within six months. “Targeted interventions might … decrease the frequency of headache revisits,” said Dr. Minen and colleagues. Dr. Minen is Director of Headache Services at NYU Langone Headache Center in New York City.
Migraine causes more than 1.2 million visits to US EDs annually. Many of these visits are revisits among patients who have already been treated in an ED for migraine. Dr. Minen and colleagues sought to determine the frequency of these headache revisits and the sociodemographic factors associated with them.
A Study of New York City EDs
Using the New York City Department of Health and Mental Hygiene Syndromic Surveillance database, Dr. Minen and colleagues conducted a retrospective nested cohort study. They analyzed visits from 18 New York City EDs with discharge diagnoses in the first six months of 2015. They then conducted descriptive analyses to determine the frequency of headache revisits within six months of an index ED visit for migraine and the elapsed time to revisit. Using multivariable logistic regression, the researchers assessed associations between age, sex, poverty, and revisit.
Of 1,052 ED visits with a discharge diagnosis of migraine during the first six months of 2015, 277 (26.3%) had a headache revisit within six months of their initial migraine visit, and 131 (12.5%) had two or more revisits at the same hospital. Of the revisits for headache, 9% occurred within 72 hours, and 46% occurred within 90 days of the initial migraine visit. Sex, age, and poverty were not associated with an ED revisit.
Noting that the revisit rate in New York City EDs was similar to the 30.3% revisit rate in a prior study in Maine EDs, the researchers said that frequent revisits for headache are not surprising. “Migraine is a recurrent headache disorder, and 80% of headache patients in the ED do not visit a clinic, primary care physician, or specialist before visiting the ED. In one urban ED, nearly 60% of ED patients were not instructed to follow-up with a physician, and approximately 40% were not prescribed medications.”
Several approaches could decrease headache revisits, the researchers said. “Within the ED, the use of evidence-based algorithms can aid in the standardization of headache diagnosis and treatment. These should include the use of dexamethasone, an evidence-based intervention to decrease the frequency of moderate or severe headache within 48 hours of ED discharge.” On discharge from the ED, patients should be advised about local headache treatment facilities. “Because ED patients with migraine and psychiatric comorbidities have higher health care utilization rates than migraine patients without psychiatric comorbidities, migraine patients with comorbid psychiatric disorders could be referred to an ED case manager to ensure further intervention.” Finally, “ED revisits for headache could be mitigated by increasing the availability and access to urgent care appointments or walk-in outpatient appointments, especially during off-hour nights and weekends,” they said.
—Glenn S. Williams
Minen MT, Boubour A, Wahnich A, et al. A retrospective nested cohort study of emergency department revisits for migraine in New York City. Headache. 2018;58(3):399-406.