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Migraine + psychiatric disorder? Too much imaging in ED.


PHILADELPHIA -- Patients who have migraines and comorbid psychiatric disorders visited the emergency department more, and received more brain imaging and narcotics, than patients who had only migraine.

The additional emergency visits and procedures--combined with significantly higher rates of hospital admissions and outpatient visits--run contrary to published recommendations, Dr. Mia Minen reported at the annual meeting of the American Academy of Neurology.

The imaging findings of her cross-sectional analysis are particularly troubling in light of cur rent guidelines aimed at helping to minimize radiation exposure by avoiding head and brain imaging in patients with primary headache disorders, said Dr. Minen, a fellow at the Graham Headache Center, Boston.

"One of the AAN's recommendations for the Choosing Wisely campaign was to not perform brain imaging for patients presenting to the ED with recurrence of their baseline primary headache disorder," she said. She added that the American College of Emergency Physicians has not found level A evidence supporting imaging in patients who present to the emergency department with headache, unless the headache is sudden and severe, or unless it's accompanied by an abnormal neurological exam.

Her analysis looked at emergency treatment trends in a database of almost 3,000 headache patients seen over a 10-year period in a single hospital's emergency department. The patients were a mean of 40 years old; most (80%) were women. About 2,000 had at least one psychiatric comorbidity; the most common psychiatric comorbidities were anxiety and depression.

Over the 10-year study period, migraine patients overall made an average of 11 ED visits, with 10 admissions and 26 outpatient visits. Those patients without a comorbid psychiatric diagnosis made significantly fewer visits in every category: 6 ED visits, 3 inpatient visits, and 11 outpatient visits.

Migraine patients with comorbidities presented a very different picture, Dr. Minen said. These patients had an average of 18 ED visits, 19 inpatient visits, and 45 outpatient visits over the study period.


Compared with migraineurs without psychiatric disorders, those with them were significantly more likely to undergo a CT of the head (relative risk, 1.4) and an MRI of the brain (RR, 1.5.). They received narcotic treatment in the ED significantly more often as well.

Caption: The ED visits and procedures of headache patients with comorbid disorders run contrary to recommendations.


Key clinical point: More studies are needed to determine why migraineurs with psychiatric disorders are more likely than those without comorbidities to undergo brain imaging and to receive narcotics.

Major finding: Migraine patients with psychiatric comorbidities were 40% more likely to have head imaging and 50% more likely to receive narcotics than those without such conditions.

Data source: The cross-sectional analysis comprised almost 3,000 patients.

Disclosures: Dr. Minen had no financial disclosures.

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Title Annotation:NEUROLOGY
Author:Sullivan, Michele G.
Publication:Clinical Psychiatry News
Date:Jul 1, 2014
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