Elsevier

General Hospital Psychiatry

Volume 36, Issue 5, September–October 2014, Pages 533-538
General Hospital Psychiatry

Emergency Psychiatry in the General Hospital1
Influence of psychiatric comorbidities in migraineurs in the emergency department,

https://doi.org/10.1016/j.genhosppsych.2014.05.004Get rights and content

Abstract

Objective

To examine how psychiatric comorbidities in migraineurs in the emergency department (ED) affect healthcare utilization and treatment tendencies.

Method

This is a cross-sectional analysis of 2872 patients who visited our ED over a 10-year period and were given a principal diagnosis of migraine.

Results

Compared to migraineurs without a psychiatric comorbidity, migraineurs with a psychiatric comorbidity had about three times more ED visits, six times more inpatient hospital stays and four times more outpatient visits. Migraineurs with psychiatric comorbidities received narcotics in the ED more often than migraineurs without psychiatric comorbidities (P<0.0001). In addition, migraineurs with psychiatric disorders were more likely to have a computed tomography scan of the head [Risk Ratio (RR) 1.42 (95% confidence interval (CI)=1.28–1.56, P<0.001)] or a magnetic resonance image of the brain [RR 1.53 (95% CI=1.33–1.76, P<0.001)] than patients without a psychiatric disorder when visiting our hospital center.

Conclusions

Migraineurs with psychiatric comorbidity who visit the ED have different healthcare utilization tendencies than migraineurs without psychiatric comorbidity who visit the ED. This is seen in the frequency of ED visits, outpatient visits and inpatient stays, in the medications administered to them and in the radiology tests they undergo.

Introduction

Migraine, an episodic headache disorder with intensely disabling attacks, affects 18% of American women and 6% of American men [1], [2]. Migraine ranks eighth among the top 10 most disabling medical conditions and is a significant public health problem with substantial medical and economic consequences [3]. Migraine accounts for the majority of the five million headache visits to US emergency departments (EDs) annually [4]. The mean cost for a migraine-related ED visit in the US is US$775. This amounts to a total national annual cost of US$700 million [5].

Migraine is strongly associated with many psychiatric comorbidities [6], [7], [8], [9], [10], [11], [12], [13], [14]. The majority (51–58%) of migraineurs will meet criteria for at least one anxiety disorder in their lifetime, [6] and over 40% have depression [8], [11]. Psychiatric comorbidities are associated with a 1.55 times increase in total migraine costs in the USA [15]. Physicians should have awareness of the psychiatric comorbidities of migraine because the psychiatric comorbidities may complicate the diagnosis, affect quality of life, affect compliance with treatment and change the course of migraine [6], [16], [17], [18], [19], [20]. Psychiatric diagnosis is associated with conversion of episodic migraine to chronic migraine, [21] which in turn is associated with almost three times higher healthcare expenditures compared to total mean episodic migraine costs [15]. Because of the high prevalence of migraine and the substantial proportion of migraine sufferers who have psychiatric comorbidity, psychiatrists, ED physicians and other healthcare providers are very likely to encounter patients with migraine and psychiatric comorbidity. There is likely a shared underlying biology, as serotonergic mechanisms seem to be implicated in both conditions [6]. Thus, the study of migraine is very relevant for the field of psychiatry.

There are few large, high-quality studies that specifically examine migraineurs who present to the ED. The American Migraine Prevalence and Prevention (AMPP) study, a population-based study, showed that a small proportion of the migraine patient population accounts for almost half of all ED visits for migraine. The AMPP researchers also found that patients who visited the ED were more likely to have depression and to be of lower socioeconomic status [22]. Few studies examine the psychiatric comorbidity of migraine patients who use the ED for treatment of their headaches. Given this paucity of information, it would be useful to better understand how psychiatric comorbidities (such as affective disorders, psychotic disorders, anxiety disorders and personality disorders) are associated with ED use in migraine patients with both conditions. Different patterns of healthcare use or treatment in this group of patients might suggest ways in which their care is deficient or could be improved.

We sought to determine whether psychiatric comorbidities in migraine patients in the ED were associated with increased healthcare utilization, specifically visits to the ED, outpatient medical visits or inpatient hospital stays, compared to migraine patients with comorbid psychiatric diagnoses. We also sought to determine whether the presence of psychiatric comorbidities was associated with the type of treatment provided in the ED. Finally, we examined whether psychiatric comorbidity was associated with the use of head imaging over the 10-year period examined in this study.

Section snippets

Methods

This was a cross-sectional analysis of data obtained from the Partners Research Patient Data Registry (RPDR). The RPDR is a computerized database that stores administrative and clinical encounter data from hospitals and clinics in the Partners Healthcare system. Partners is a nonprofit organization of eight hospitals and other healthcare providers. It is the largest healthcare provider in Massachusetts and has a substantial share of the market in the greater Boston metropolitan area.

The RPDR

Results

Two thousand eight hundred seventy-two patients between the ages of 18–64 visited the hospital ED between January 1, 2003 and December 31, 2012 and received a principal diagnosis of migraine. Of these, 1037 had at least one psychiatric comorbidity and 1829 did not. Table 2 shows selected demographic characteristics of the overall population of patients and the two subgroups of patients with and without psychiatric comorbidity. Patients with psychiatric comorbidity were more likely to be female

Discussion

In this detailed examination of how psychiatric comorbidities affect migraineurs' healthcare utilization pattern and treatment, we identified the following themes: (a) The migraine patients with psychiatric disorders in our study had more ED visits, outpatient visits and inpatient visits than the migraine patients without psychiatric disorders; (b) Compared to migraineurs without psychiatric comorbidities, migraineurs with psychiatric comorbidities were administered narcotics more frequently;

Conclusion

Our study shows that much work needs to be done to better treat patients who are diagnosed with migraine in the ED, especially those with psychiatric comorbidities. The patients are receiving medications not recommended by consensus statements, as evidenced by the fact that narcotics comprised 28% of the medication administrations in all migraine patients queried in the study. Furthermore, the narcotics are administered more to migraineurs with psychiatric comorbidity compared to those without

Acknowledgments

We wish to acknowledge Dr. Elizabeth Loder for her critical review of the manuscript.

References (34)

  • J. Edmeads et al.

    Impact of migraine and tension-type headache on life-style, consulting behaviour, and medication use: a Canadian population survey

    Can J Neurol Sci

    (1993)
  • B.K. Rasmussen et al.

    Impact of headache on sickness absence and utilisation of medical services: a Danish population study

    J Epidemiol Community Health

    (1992)
  • T. Vos et al.

    Years lived with disability (YLDs) for 1160 sequelae of 289 diseases and injuries 1990–2010: a systematic analysis for the global burden of disease study 2010

    Lancet

    (2012)
  • D.R. Vinson

    Treatment patterns of isolated benign headache in US emergency departments

    Ann Emerg Med

    (2002)
  • R.P. Insinga et al.

    Costs associated with outpatient, emergency room and inpatient care for migraine in the USA

    Cephalalgia

    (2011)
  • S.M. Baskin et al.

    Migraine and psychiatric disorders: comorbidities, mechanisms, and clinical applications

    Neurol Sci

    (2009)
  • R. Amouroux et al.

    Anxiety and depression in children and adolescents with migraine: a review of the literature

    Encéphale

    (2008)
  • F. Antonaci et al.

    Migraine and psychiatric comorbidity: a review of clinical findings

    J Headache Pain

    (2011)
  • S.M. Baskin et al.

    Mood and anxiety disorders in chronic headache

    Headache

    (2006)
  • N. Breslau

    Psychiatric comorbidity in migraine

    Cephalalgia

    (1998)
  • D.C. Buse et al.

    Psychiatric comorbidities of episodic and chronic migraine

    J Neurol.

    (2013)
  • S.W. Hamelsky et al.

    Psychiatric comorbidity of migraine

    Headache

    (2006)
  • A.E. Lake et al.

    Headache and psychiatric comorbidity: historical context, clinical implications, and research relevance

    Headache

    (2005)
  • F. Radat et al.

    Psychiatric comorbidity in migraine: a review

    Cephalalgia

    (2005)
  • M. Stokes et al.

    Cost of health care among patients with chronic and episodic migraine in Canada and the USA: results from the international burden of migraine study (IBMS)

    Headache

    (2011)
  • A.I. Scher et al.

    Risk factors for headache chronification

    Headache

    (2008)
  • T.A. Smitherman et al.

    Anxiety disorders and migraine intractability and progression

    Curr Pain Headache Rep

    (2008)
  • Cited by (20)

    • Introduction of a smartphone based behavioral intervention for migraine in the emergency department

      2021, General Hospital Psychiatry
      Citation Excerpt :

      The prevalence of psychiatric comorbidities associated with migraine, including anxiety, depression, bipolar disorder and post-traumatic stress disorder, is high and often overlooked [15–17]. Patients with migraine and a psychiatric comorbidity have higher healthcare utilization rates than patients with migraine without psychiatric comorbidities [18]. Further, if untreated, comorbid psychiatric conditions can negatively impact treatment outcomes, lead to migraine progression, increase migraine-related disability, and reduce quality of life for migraine patients [19–21].

    • Emergent neuroimaging for seizures in epilepsy: A population study

      2020, Epilepsy and Behavior
      Citation Excerpt :

      We also found that patients with psychiatric comorbidities were more likely to undergo neuroimaging. To our knowledge, this has not been previously described in patients with epilepsy, but higher imaging utilization among patients with psychiatric comorbidities has been described in patients in the general population and in patients with other chronic neurologic disorders like migraine [15,16]. Previous published studies of adult patients with epilepsy presenting to the ED for seizure have described an emergent neuroimaging rate of 39–46% with only 3–8% of the scans resulting in acute change in patient management [17,18].

    • Migraine and Mental Health in a Population-Based Sample of Adolescents

      2017, Canadian Journal of Neurological Sciences
    • Migraine in bipolar disorder and schizophrenia: The hidden pain

      2023, International Journal of Psychiatry in Medicine
    View all citing articles on Scopus

    There was no financial support for the research.

    1

    The emergency room is the interface between community and health care institution. Whether through outreach or in-hospital service, the psychiatrist in the general hospital must have specialized skill and knowledge to attend the increased numbers of mentally ill, substance abusers, homeless individuals, and those with greater acuity and comorbidity than previously known. This Special Section will address those overlapping aspects of psychiatric, medicine, neurology, psychopharmacology, and psychology of essential interest to the psychiatrist who provides emergency consultation and treatment to the general hospital population.

    View full text