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Migraine: A Diagnostic Dilemma in the Emergency Department

During an acute migraine attack, one of the most frustrating events for the migraineur is the realization that the prescription medication is not working, assuring the necessity of a visit to the local emergency department (ED). At the ED, the patient will suffer with the headache, and a several-hour wait until evaluation and treatment is common. Too often, the lack of the correct diagnosis and inappropriate or ineffective treatment is the scenario that the patient with migraine will experience. The study reported by Morgenstern et al in this issue of Headache illustrates what several retrospective studies have previously demonstrated 1-5 —that headache is the primary complaint in about 1% of patients seen in the ED. It is important to note that most patients are given a diagnosis of benign headache . This is a medicolegal term and not helpful in therapeutics. The authors indicate that, even today, ED physicians have little training in migraine recognition and treatment. The goal of the ED physician has always been to avoid missing a catastrophic event (subarachnoid hemorrhage, meningitis), and yet we are seeing a more common disorder—migraine—more frequently. Only 17% of patients received this diagnosis, and yet the studies quoted for acute headache intervention in the ED involved patients with migraine. 6-8