Majority of Canadian Physicians Treat Primary Headache Disorders With Nonsteroidal Anti-inflammatory Drugs, Dopamine Receptor Antagonists

Dilan Patel, MSc

A recent national survey conducted in Canada resulted in showing that majority of emergency physicians treat primary headache disorders using nonsteroidal anti-inflammatory drugs (NSAIDs) alone and dopamine receptor antagonists, with or without ketorolac coadministration.¹ In the emergency department, treatment for primary headache disorders is not always consistent with regard to the use of the most effective options for physicians.

Pharmacotherapies that were commonly used for primary headaches disorders included intravenous dopamine receptor antagonists (69%), coadministration of ketorolac and a dopamine receptor antagonist (54.2%), intravenous fluid boluses (54%), NSAIDs alone (53.5%), and acetaminophen (51.4%).¹

Out of 144 physicians surveyed, 80 (55.6%) reported previous experience with peripheral nerve blocks (95% CI, 48-65). The majority of those who had past experience (85.0%) agreed peripheral nerve blocks are safe and 55.1% agreed that they are effective. Notably, the majority out of all the physicians would consider peripheral nerve blocks as a first-line treatment option if there were sufficient evidence given from a future trial (84.3%; 95% CI, 78-90).

Dilan Patel, MSc, clinical research coordinator, Clinical Epidemiology Program, Department of Emergency Medicine, Ottawa Hospital Research Institute, and colleagues noted, “the majority of physicians will use IV dopamine receptor antagonists, IV NSAIDs, oral acetaminophen, and a combination therapy consisting of ketorolac and a dopamine receptor antagonist, as the main pharmacotherapies for primary headaches in the emergency department. As suspected, the frequency of use of opioids and other sedatives (ie, propofol and ketamine) was low, with the majority of physicians prescribing them almost never or never.”

The researchers surveyed 500 emergency physicians listed in the Canadian Medical Directory according to a modified Dillman method and after the initial invitation, there was a follow-up of up to 4 reminders for nonresponders. The physicians were asked questions in the survey about their frequency of medication administration and their perspectives toward peripheral nerve block. From the initial 500 mailed surveys, only 468 were delivered and 179 physicians responded with a response rate of 38.2%. Of the physicians who responded completely (n = 144), 63.9% were men and 80.6% had been in practice for at least 10 years with 50.7% being at a community or district general teaching hospital.

Monica Taljaard MD, senior scientist, Clinical Epidemiology Program, Ottawa Hospital Research Institute, full professor of epidemiology and community medicine, University of Ottawa, and colleagues wrote that in their survey, “a large proportion of emergency physicians have never performed a peripheral nerve block; however, they would consider one as a first-line treatment option given sufficient evidence from an [randomized controlled trial].” Furthermore, this result revealed to be consistent with a recent observational study in which only 1.8% (10 of 553), of cases treated primary headaches in the emergency department with peripheral nerve blocks.²

The study’s limitations included the low response rates and also the generalizability of the results, as the physician demographics in the survey were similar to those listed in the emergency medicine profile of the Canadian Medical Association. Taljaard et al wrote, “There may be some uncertainty among emergency physicians as to which peripheral nerve block; to use for specific subtypes of headache; the majority of physicians would not consider peripheral nerve blocks for migraine.” Peripheral nerve blocks may be used on any primary headache presentations if they are more effective than standard treatment options without the need to vary or alter pharmacotherapies with known side effects.

REFERENCES
1. Patel D, Taljaard M, Yadav K, James D, Perry JJ. Current practice for primary headache disorders and perspectives on peripheral nerve blocks among emergency physicians in Canada: A national survey. Headache. 2022;62(4):512-521. doi:10.1111/head.14293
2. Wells S, Stiell IG, Vishnyakova E, Lun R, Nemnom MJ, Perry JJ. Optimal management strategies for primary headache in the emergency department. CJEM. 2021;23(6):802-811. doi:10.1007/s43678-021-00173-0