Treating Headache Recurrence After Emergency Department Discharge: A Randomized Controlled Trial of Naproxen Versus Sumatriptan
Friedman BW, Solorzano C, Esses D, et al
Ann Emerg Med. 2010;56:7-17
Introduction
Annually, headaches account for more than 3 million emergency department (ED) visits in the United States. Unfortunately, headache recurrence after successful ED treatment is more the rule than the exception. Although estimates vary widely, moderate or severe headache was present within 24 hours of ED discharge in 31% of migraine patients, 19% of tension-type headache patients, and 27% of unclassifiable headache patients.
This prevalence stands in contrast to the limited research that addresses prevention or treatment of postdischarge headache recurrence. Although dexamethasone, naproxen, and tryptamine-based drugs have received attention as prophylactic or treatment alternatives after headache occurrence, no standard approach to the treatment or prevention of postdischarge headache recurrence exists. With little evidence to guide their decisions, most emergency physicians prescribe nonsteroidal or opioid therapies to patients on discharge from the ED; however, the impact of these therapies for individual patients is poorly understood and generally invisible to the treating emergency physician.
Summary
In the most recent edition of the Annals of Emergency Medicine, Benjamin Friedman and colleagues from Montefiore Medical Center, Columbia University Medical Center, and the University of South Alabama report the results of a randomized double-blind comparison of oral naproxen 500 mg or sumatriptan 100 mg for headache recurrence among patients discharged from the ED after receiving parenteral reatment for primary headache. The primary outcome of interest was the change in pain intensity 2 hours after taking either study drug for the treatment of recurrent headache. Secondary outcomes were patient preference for the study medication, and the incidence of adverse effects.
Over 50% of 401 subjects discharged from the ED (almost all of whom received antiemetic/dopamine antagonist therapy) reported a recurrence of headache of sufficient intensity to require analgesics. Subjects meeting criteria for migraine reported pain intensity scores of 8 (on a 0-10 scale) with similar mean reductions in pain intensity 2 hours after ingesting naproxen (4.3 units) or sumatriptan (4.1 units), and a mean difference in improvement of 0.2 units (95% confidence interval, -0.7 to 1.1). Among subjects with primary headache who did not fulfill criteria for migraine, results were virtually identical. Adverse effects of any type were reported by 19% of those receiving naproxen and by 26% of those assigned to sumatriptan. Almost three fourths of subjects in each group reported that under similar circumstances they would take the same medication again.
Viewpoint
Perhaps the most important message from this study is that ED patients treated for primary headaches should be informed that headache recurrence is likely and should receive analgesic prescriptions to treat potential recurrent symptoms at the time of discharge. Given similar outcomes after treatment with naproxen or sumatriptan, cost and adverse effect profiles would seem to favor naproxen, although patient preference and past experience with analgesics should guide selection. A significant minority of patients reported that they would not take the same medication again. Future studies should investigate other options, including the use of antiemetic dopamine antagonists, or multimodal therapy with various combinations of nonsteroidal, tryptamine-based, and antiemetic therapies.
Abstract