Faculty Bibliography

BACKGROUND: Published data from 1998 revealed that most patients treated for migraine in an emergency department received opioids. Over the intervening years, a large body of evidence has emerged demonstrating the efficacy and safety of non-opioid alternatives. Expert opinion during these years has cautioned against use of opioids for migraine. Our objectives were to compare current frequency of use of various medications for acute migraine in US emergency departments with use of these same medications in 1998 and to identify factors independently associated with opioid use. METHODS: We analyzed National Hospital Ambulatory Medical Care Survey data from 2010, the most current dataset available. The National Hospital Ambulatory Medical Care Survey is a public dataset collected and distributed by the Centers for Disease Control and Prevention. It is a multi-stage probability sample from randomly selected emergency departments across the country, designed to be representative of all US emergency department visits. We included in our analysis all patients with the ICD9 emergency department discharge diagnosis of migraine. We tabulated frequency of use of specific medications in 2010 and compared these results with the 1998 data. Using a logistic regression model, into which all of the following variables were entered, we explored the independent association between any opioid use in 2010 and sex, age, race/ethnicity, geographic region, type of hospital, triage pain score and history of emergency department use within the previous 12 months. RESULTS: In 2010, there were 1.2 (95% confidence interval 0.9, 1.4) million migraine visits to US emergency departments. Including opioid-containing oral analgesic combinations, opioids were administered in 59% of visits (95% confidence interval 51, 67). The most commonly used parenteral agent, hydromorphone, was used in 25% (95% confidence interval 19, 33) of visits in 2010 versus less than 1% (95% confidence interval 0, 3) in 1998. Conversely, use of meperidine had decreased markedly over the same timeframe. In 2010, it was used in just 7% (95% confidence interval 4, 12) of visits compared to 37% (95% confidence interval 29, 45) in 1998. Metoclopramide, the most commonly used anti-dopaminergic, was administered in 17% (95% confidence interval 12, 23) of visits in 2010 and 3% (95% confidence interval 1, 6) of visits in 1998. Use of any triptan was relatively uncommon in 2010 (7% (95% confidence interval 4, 11) of visits) and in 1998 (10% (95% confidence interval 6, 15) of visits). Of the predictor variables listed above, only emergency department use within the previous 12 months was associated with opioid administration (adjusted odds ratio: 2.87 (95% confidence interval 1.03, 7.97)). CONCLUSIONS: In spite of recommendations to the contrary, opioids are still used in more than half of all emergency department visits for migraine. Though use of meperidine has decreased markedly between 1998 and 2010, it has largely been replaced by hydromorphone. Opioid use in migraine visits is independently associated with prior visits to the same emergency department in the previous 12 months.

OBJECTIVE/BACKGROUND: This study aims to determine why patients with migraine present to an emergency department (ED). While migraine accounts for over 800,000 ED visits annually, no prospectively gathered data characterize patients' reasons for presenting to an ED. METHODS: We prospectively interviewed 309 consecutive patients presenting to an urban ED for headache. Patients were asked 100 closed-ended questions regarding sociodemographics, headache history, and current headache attack. We performed descriptive analyses on patients fulfilling International Classification of Headache Disorders 2 migraine criteria. RESULTS: Of 186 patients who met migraine criteria, 77% (95% confidence interval [CI]: 71, 83%) had a primary care provider (PCP), 87% (95% CI: 82, 92%) had medical insurance, and 83% (95% CI: 77, 88%) had drug coverage. Fifty-three percent (95% CI: 46, 60%) reported that they previously visited a doctor for headache. Fifty-five percent (95% CI: 48, 62%) previously received a migraine diagnosis. Twenty-two percent (95% CI: 16, 28%) sought medical care for the current headache prior to ED presentation. Fifty-five percent (95% CI: 48, 63%) took abortive medication for migraine on the day of the ED visit. Median headache duration was 24 hours (IQR: 12-72). Forty-nine percent (95% CI: 42, 57%) screened positive for depression. The most common reason for visiting the ED was a perceived emergency condition or referral by a physician (33.3% [95% CI: 27, 40%]). Other commonly cited reasons related to access to care. CONCLUSIONS: Most migraineurs presenting to the ED have a PCP and health insurance. ED visits commonly result from an inability to access care elsewhere and because patients consider pain to be an emergency condition. Missed opportunities for diagnosis and treatment likely contribute to ED visits.

Patients presenting with tinnitus commonly have neuropsychiatric symptoms with which physicians need to be familiar. We provide an overview of tinnitus, including its types and pathophysiology. We discuss how recent methods such as transcranial magnetic stimulation, positron emission tomography, MRI, magnetoencephalography and quantitative EEG improve our understanding of the pathophysiology of tinnitus and connect tinnitus to the neuropsychiatric symptoms. We then explain why treatment of the tinnitus patient falls within the purview of neuropsychiatry. Psychiatric problems such as depression, anxiety and personality disorders are discussed. We also discuss how stress, headache, cognitive processing speed and sleep disturbance are associated with tinnitus. Finally, we provide a brief overview of treatment options and discuss the efficacy of various medications, including benzodiazepines, antidepressants, antipsychotics and mood-stabilising agents, and various non-pharmacological treatment options, such as cognitive behavioural therapy, habituation therapy and acupuncture. We also discuss how brain stimulation therapies are being developed for the treatment of tinnitus. In conclusion, a review of the literature demonstrates the varied neuropsychiatric manifestations of tinnitus. Imaging studies help to explain the mechanism of the association. However, more research is needed to elucidate the neurocircuitry underlying the association.

OBJECTIVE: To examine how psychiatric comorbidities in migraineurs in the emergency department (ED) affect healthcare utilization and treatment tendencies. METHOD: This is a cross-sectional analysis of 2872 patients who visited our ED over a 10-year period and were given a principal diagnosis of migraine. RESULTS: Compared to migraineurs without a psychiatric comorbidity, migraineurs with a psychiatric comorbidity had about three times more ED visits, six times more inpatient hospital stays and four times more outpatient visits. Migraineurs with psychiatric comorbidities received narcotics in the ED more often than migraineurs without psychiatric comorbidities (P<0.0001). In addition, migraineurs with psychiatric disorders were more likely to have a computed tomography scan of the head [Risk Ratio (RR) 1.42 (95% confidence interval (CI)=1.28-1.56, P<0.001)] or a magnetic resonance image of the brain [RR 1.53 (95% CI=1.33-1.76, P<0.001)] than patients without a psychiatric disorder when visiting our hospital center. CONCLUSIONS: Migraineurs with psychiatric comorbidity who visit the ED have different healthcare utilization tendencies than migraineurs without psychiatric comorbidity who visit the ED. This is seen in the frequency of ED visits, outpatient visits and inpatient stays, in the medications administered to them and in the radiology tests they undergo.

Head pain is the fifth most common reason for emergency department (ED) visits. It is second only to focal weakness as the most common reason for neurological consultation in the ED. This manuscript reviews how patients with migraine, the most common primary headache disorder for which patients seek medical treatment, are managed in the ED. We discuss existing guidelines for head imaging in patients with migraine, recommended pharmacologic treatments, and current treatment trends. We also review studies evaluating the discharge care of migraine patients in the ED. With the goal of standardizing, streamlining, and optimizing ED-based migraine care, we offer ideas for future research to improve the evaluation, treatment, and discharge care of patients who present to an ED with acute migraine.

OBJECTIVE: We sought to examine the relationship of family history of headache and family history of psychiatric disorders on self-reported health care utilization tendencies for migraine treatment. BACKGROUND: Familial aggregation of both migraine and depression has been well established in the literature. Family history of headache and psychiatric disorders could influence health care utilization tendencies for migraine. METHODS: This is a secondary analysis of patients with severe migraine (n = 225) who answered questions about their family history, previous headache treatment history, disability (Headache Disability Inventory), and psychiatric symptoms (Beck Depression Inventory and Beck Anxiety Inventory). Using regression, we examined the relationship between family history of headache, depression, and anxiety and reported headache-related health care utilization. RESULTS: Participants reported family histories of headache (67.6%), anxiety (15.6%), and depression (29.3%). Participants reported seeing a physician for headache an average of 3.1 (standard deviation = 3.8) times in the past 2 years. In a 2-year period, 27.6% of participants reported seeing a general practitioner and 18.5% of participants reported seeing a neurologist. Twenty-eight percent of participants went to urgent care for headaches at least once in the last 2 years. Thirty-nine percent of participants reported using non-pharmacologic treatment for headache in the prior 2 years, with the highest rates of chiropractic manipulation (27.1%) and massage (18.2%), and fewest rates of biofeedback (0.4%), relaxation training (4.4%), psychotherapy (1.8%), physical therapy (4.9%), or acupuncture (1.8%). Family history of anxiety was associated with trying non-pharmacologic treatments for headache, but no other self-reported health care utilization variable. However, neither family history of headache nor family history of depression was associated with self-reported health care utilization tendencies. Headache Disability Inventory was associated with self-reported non-pharmacologic treatments for headache. CONCLUSIONS: Family history of anxiety, but not depression, was associated with utilizing non-pharmacologic treatments for headache. Also, disability was associated with utilizing non-pharmacologic treatments for headache. However, participants reported low rates of utilization for non-pharmacologic treatments with grade-A evidence.

Physicians who are insufficiently prepared to make choices on antibiotic selection may use antibiotics inappropriately. We surveyed medical students' perceptions and attitudes about their training on antimicrobial use to identify gaps in medical education. Medical students at an urban medical school in the northeast were e-mailed a link to an online survey. The survey was online for 1 week, after which time the survey responses were downloaded and analyzed. Thirty percent of medical students responded to the survey (n = 304). The majority of third- and fourth-year medical students believe that antibiotics are overused in the hospital and in outpatient areas. Over three quarters of the students would like more education on antibiotic selection, and 83% wanted this education to be during the third year of medical school. The resources they used the most for antibiotic selection included other physicians and handheld programs such as Epocrates, but no clear resource emerged as the dominant preference. Medical students recognized the importance of judicious antibiotic use and would like greater instruction on how to choose antibiotics appropriately. Medical school curricula should be expanded in the third year of medical school to provide students with additional training timed with their clinical rotations.