Most of us with frequent or severe migraines have considered going to the emergency room due to our migraines at one time or another. I have frequently heard those with migraines debate the pros and cons of going to the emergency department (ED). The most common reasons I have heard migraineurs give are that they can't endure the pain, can't break their current migraine cycle, can't get in touch with their doctor, or are afraid that something more serious than their "regular" migraine is occurring. Interestingly enough, there are few research studies that seek to identify the primary reasons for presentation to the emergency department. Minen, Loder & Friedman sought to answer this question in the research poster they presented at the American Headache Society meeting in June, 2014.
The Research Poster:
"To determine why patients with migraine present to an emergency department (ED)."
"Although migraine accounts for more than 8000,000 ED visits annually resulting in an estimated yearly expenditure of $700,000, the researchers were not able to find any statistical data examining the "reasons for an ED visit for headache."
- 309 consecutive headache patients presenting to an urban ED were asked 100 close-ended questions those that have a about "sociodemographics, headache history, and current headache attack." (Close-ended questions are a format that provides a list of answer choices from which respondents must choose in order to answer the question.)
- Results of any administered brain imaging or spinal taps were recorded for each of these patients.
- Two ED physicians coded the type of headache according to the criteria in the International Classification of Headache Disorders, 2nd Edition (ICHD-2). (This research was conducted prior to the implementation of the International Classification of Headache Disorders, 3rd (ICHD-3) which is currently being used; therefore, the ICHD-2 criteria was utilized.)
- 186 of the presenting patients met migraine criteria under ICHD-2.
- 77% had a primary care provider (PCP).
- 90% had medical insurance.
- 83% had drug coverage.
- 53% had previously visited a doctor due to headaches.
- 55% had previously received a migraine diagnosis.
- 22% sought medical care for the current headache prior to ED presentation.
- 55% took abortive medication for migraine the day of the ED visit.
- The median headache duration was 24 hours. (The median is the middle value in a list of numbers, not the average of the numbers.)
- 49% screened positively for depression.
- The most common reason for the ED visit was either a perceived emergency or referral by an MD.
- Another frequently cited reason for ED visit related to access to care.
"ED visits result from an inability to access care elsewhere and because patients consider pain to be an emergent condition."
Summary and What This Means for Us
Minen, Loder and Friedman theorize that "missed opportunities for diagnosis and treatment likely contribute to ED visits." This study suggests that patients frequently decide to go to the ED because they feel they have no other viable alternative at the time and because they perceive the level of pain that they are currently experiencing to constitute an emergency. This study has implications for both us as patients and for our doctors.
First, it's important for the patient and physician to discuss how we can access after-hours care. We should also know what to do if the predetermined arrangement for after-hours care is inaccessible. For example, our doctor may tell us to contact their answering service if we are experiencing any new or increased symptoms that alarm us after-hours or if we are unable to control pain or vomiting. In that case, we also need to know what to do if we don't hear back from the doctor and how long it is reasonable to wait for a return call.
Secondly, we need to know what kinds of situations actually indicate a need for after hours-care. We need to know under what circumstances we should go to the ED immediately. We also need to have some means of knowing when and if pain is a medical emergency. While, it is generally accepted that any new or increased symptoms need to be discussed with one's doctor, this needs to be discussed in advance with our doctors in order to help us determine when something is a medical emergency, when it can wait until the doctor's office is next open, or when it can wait until our next appointment. Clearly, there are no hard and fast rules about this as all medical situations and individuals are different; however, having discussed the use of ED care in advance with our personal physician can aid us in making an informed decision.
Some of the questions below are easier to answer and have more concrete answers than others, but they're well worth discussion with our doctors. You may want to take this list of questions in to discuss with your doctor during your next visit:
- How do I contact you after hours?
- How long should I expect to wait to hear back from you?
- Under what circumstances is it appropriate to call you after hours?
- How do I determine if I should go to the ED or call you first?
- How do I determine if I need to come in to see you right away or wait for my next appointment?
- Do you have any instructions that I should provide the ED doctor?
- How do I know when pain, vomiting or other symptoms rise to the level of an emergency?
There's a lot to be said for the saying that "knowledge is power." In talking with many fellow patients, I've found that those who have a clear understanding of their diagnosis, a clear-cut treatment plan for both "normal" and emergency care, and a specific means of communicating with their doctor tend to be more confident in determining when it is necessary to go to the ED. As Minen, Loder and Friedman suggest. diagnosis and treatment plans may help reduce the number of ED visits.
Minen,M.T.; Loder, E.W.; Friedman,B. "Factors Associated with Emergency Department Visits for Migraine: An Observational Study." Poster Presentation. 56th Annual Scientific Meeting; American Headache Society. Los Angeles. June, 2014.
Wishing you health, hope & happiness,