Reviewing ACEP guidelines on acute nontraumatic headache diagnosis and management in the emergency department

The Society’s Refractory, Inpatient, Emergency Care Special Interest Section provides a headache specialist perspective

The American College of Emergency Physicians (ACEP) published guidelines in 2019 on the diagnosis and management of acute non-traumatic headache in the emergency department. A commentary published in Headache® on behalf of the Refractory, Inpatient and Emergency Care Special Interest Section provides headache specialists’ perspective on the guidelines.

We spoke about the guidelines with commentary lead author Addie Peretz, MD. She currently serves as a headache and facial pain specialist at Stanford Health Care. We also discussed the guidelines’ real-world applications in Emergency Departments. While the ACEP guidelines also reviewed various means of better or more accurately diagnosing acute subarachnoid hemorrhage, Dr. Peretz focused her commentary on one specific aspect: the preferential use of non-opiate medications in the treatment of acute primary headaches in the emergency department.

Non-opiate recommendations

In the commentary, the authors note the current practice of prescribing opioids for the management of acute migraine is widespread. For instance, nearly 20% of patients attending a tertiary care headache center for the treatment of migraine reported that they first received opioids in the emergency department.

The authors also approve the ACEP Clinical Policy’s preference of non-opioid medications for adult ER patients with acute primary headaches. “It is a greatly appreciated position that promotes patient-safe and positive treatments of acute primary headaches,” they write. Dr. Peretz believes this will have a positive effect on emergency care for patients with headache. “Now emergency physicians can be empowered with support from the ACEP guidelines to educate patients that [opiates are] not the appropriate means of treatment,” says Dr. Peretz.

Additionally, the commentary highlights other potential non-opiate treatment options that could be helpful for patients in the Emergency Department setting. This includes alternate injectable or intravenous therapies, nerve blocks, new medications and neuromodulatory devices. “Some of these new and emerging therapies for acute migraine treatment have the potential to be effective in the Emergency Department setting and deserve attention,” says Dr. Peretz. She hopes the commentary helps highlight viable opiate alternatives for providers.

Possibilities for implementation

According to Dr. Peretz, it was important that the commentary not just provide Emergency Department physicians with the rationale to choose non-opioid measures. Its purpose extended to offering the tools to support doctors as they look after patients with headache disorders. These non-opioid options can be integrated into Emergency Room care via ordersets or through a Migraine Action Plan. Examples of this include the MAP developed by Dr. Peretz and her fellow Section members and co-authors Mia T. Minen, MD, MPH, FAHS, Lauren Doyle Strauss, MD, and Robert Cowan, MD, FAHS.

A Migraine Action Plan is a written plan for preventing and treating migraine attacks agreed upon by physician and patient. According to Dr. Peretz, a patient requiring acute care can take their plan to the Emergency Room. In this way, the ER physician doesn’t have to “reinvent the wheel,” and has recommendations from the patient’s primary provider. “It’s up to the discretion of the Emergency Room physician to determine what’s appropriate, and the Migraine Action Plan may help providers with suggestions for care based on the patient’s discussions with their outpatient providers.”

Dr. Peretz has also worked to create an algorithm for acute migraine management in the Emergency Department which is accessible to ED physicians at https://curbsidehealth.com/. This site, created by Dan Imler, MD, is a decision assistant with full Electronic Health Record integration. It includes acute headache diagnosis and management pathways with recommendations for medications during care in the ER and upon discharge.

A Special Interest Section making a difference

The Refractory, Inpatient and Emergency Care Section at the AHS first caught Dr. Peretz’s eye a few years ago after she attended an International Headache Academy meeting and saw Zubair A. Ahmed, MD, present data on reducing opioid use in his emergency department through use of an algorithm. “That inspired me to try work to improve the care of patients presenting with acute headaches at my home institution’s Emergency Department ,” she says.

Since then, she says, she’s worked to push forward any Section work that can improve the care of patients who do end up in the emergency room, or, find ways to help patients avoid the need for Emergency Room care. “This section is a great platform for discussing what we can be doing to support our patients outside the clinic,” Dr. Peretz says, pointing to the Migraine Action Plan as just one example of the work originated from the Section.

According to Dr. Peretz, physician partnership is central to these initiatives. “As a headache specialist, one thing that’s very important to me is how can I best support my colleagues who are also seeing patients and who are often the first touch point for our patients.” Her hope is that further research and collaboration continues to better patient care.

Headache®: The Journal of Head and Face Pain is the official journal of the American Headache Society. AHS frequently reviews published research and provides commentary on the work being done to help advance the understanding of headache and face pain. For more analysis on studies published in Headache®, visit the AHS News page.