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ED visits for headache pain on the rise among children
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SAN FRANCISCO — The rates of ED visits, and ensuing hospital admission, increased significantly among children presenting with non-traumatic, non-febrile headaches, according to data presented at the 2016 AAP National Conference and Exhibition.
“The number of children presenting in our pediatric emergency department with headache is increasing over time,” Michelle Perry, MD, a pediatric resident at Children’s Hospital of Pittsburgh of UPMC, told Infectious Diseases in Children. “It is not uncommon to see patients and parents that have missed significant amounts of school or work because of chronic headaches.”
To estimate the frequency of headache visits to pediatric EDs, Perry and colleagues used EMR data to examine children aged 4 to 20 years who presented with ICD-9 diagnosis codes for headache from 2007 to 2014.
The researchers randomly selected 50 visits per year to illustrate demographics and management, using variables such as age, gender, race, ethnicity, chief complaint, head injury within 48 hours, history of concussion, pre-hospital medication, fever, imaging obtained during the encounter, pharmacological therapy received in ED, diagnosis, admission status and length of admission.
Among the 10,342 patients who visited the ED with an ICD-9 code, 2,247 patients were admitted for treatment. Researchers found that visits resulting from headaches increased 111% from 896 visits in 2007 to 1,887 visits in 2014; subsequently, pediatric ED visits increased by 30% during the study period.
Despite the increased headache-related visits and admissions, researchers found that CT frequency decreased 3.7% (r = -.926, P = .001) each year from 34% in 2007 to 18% in 2014. In addition, pharmacological therapy for headaches increased 2.9% (r = .71, P = .049) each year from 76% in 2007 to 88% in 2014. Girls were hospitalized for headache more often than boys.
“More children are admitted to the hospital for headache than they were in prior years,” Perry said in an interview. “Now more than ever, we need to examine possible reasons why this might be happening and strategize better treatment methods for headaches in children.” – by Kate Sherrer
Reference:
Perry MC, et al. Abstract #319802. Presented at: AAP National Conference and Exhibition; Oct. 22-25, 2016; San Francisco, California.
Disclosure: Perry reports no relevant financial disclosures.
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Gigi Chawla, MD
This is a very interesting article that should push people to investigate why more children are presenting to the emergency room for headaches in Pittsburgh. The breadth of factors at play are immense, including diminished access to primary care, increased stress/anxiety in our children, or increased rates of organic disease to name a few. What was wonderful to note, is the decreased use of radiation exposure for managing these children.
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Daniel M. Fein, MD
At the Children's Hospital at Montefiore, we too often see children and adolescents who have a chief complaint of headache. While it is indeed concerning that the rate of ED visits for headaches and subsequent hospitalizations have doubled over the study period, it is extremely encouraging that despite this increase in visits, the number of children who are receiving ionizing radiation, which we know has long-term adverse outcomes, has decreased.
It is also reassuring that more of these children presenting with headaches are receiving analgesia, as we know that providing adequate analgesia for children is something that we constantly need to improve. The key is working with families, their primary care physicians, and if applicable, their neurologists to find treatment strategies that can both limit ED visits and hospitalizations.
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Mia T. Minen, MD, MPH
There are many ED visits for headache in both the pediatric and adult populations. This study does not specify the headache diagnosis given to the patients when discharged from the ED, thus it is unknown how many were diagnosed as migraine or other primary headache disorders versus how many were diagnosed with underlying tumors, infections, etc. However, given the epidemiology of migraine, it is probably reasonable to assume that a significant number of the patients had migraine.
While we have preventive migraine medications, primary care physicians (pediatricians and internists) are oftentimes uncomfortable prescribing these medications. This is unfortunate because the medications can be well tolerated and effective in preventing migraines. Longterm, they can help prevent ED visits.
Physicians may not realize how disabling migraines can be and thus may not prescribe triptans, the migraine specific class of abortive medications (medications that can stop the migraine). However, it is important to make sure that known migraine patients have various migraine abortive medications to use at home to hopefully prevent ED visits. This includes having an anti-nausea medication for patients who have nausea as part of their migraine syndrome.
Recently, the American Headache Society released guidelines for the acute treatment of migraine in adults. While children should not be considered "little adults," there may be some take-a-way points for pediatric ED physicians to learn which medications, in general, have better efficacy for the treatment of migraine in the ED.
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