Skip to main page content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

Https

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
. 2021 Jul 28;6(4):e443.
doi: 10.1097/pq9.0000000000000443. eCollection 2021 Jul-Aug.

Standardized Headache Therapy in the Pediatric Emergency Department Using Improvement Methodology

Adam A Vukovic  1   2 , Selena Hariharan  1   2 , Michelle C Caruso  3 , Sara M Zellner  4 , Marielle Kabbouche  1   5 , Stephen C Porter  1   2 , Eileen Murtagh-Kurowski  1   2
Affiliations

Standardized Headache Therapy in the Pediatric Emergency Department Using Improvement Methodology

Adam A Vukovic et al. Pediatr Qual Saf. .

Abstract

Introduction: Primary headache is a common cause of pediatric emergency department (PED) visits. Without published guidelines to direct treatment options, various strategies lacking evidence are often employed. This study aims to standardize primary headache treatment in the PED by promoting evidence-based therapies, reducing nonstandard abortive therapies, and introducing dihydroergotamine (DHE) into practice.

Methods: A multidisciplinary team developed key drivers, created a clinical care algorithm, and updated electronic medical record order sets. Outcome measures included the percentage of patients receiving evidence-based therapies, nonstandard abortive therapies, DHE given after failed first-line therapies, and overall PED length of stay. Process measures included the percent of eligible patients with the order set usage and medications received within 90 minutes. Balancing measures included hospital admissions and returns to the PED within 72 hours. Annotated control charts depicted results over time.

Results: We collected data from July 2017 to December 2019. The percent of patients receiving evidence-based therapies increased from 69% to 73%. The percent of patients receiving nonstandard abortive therapies decreased from 2.5% to 0.6%. The percent of patients receiving DHE after failed first-line therapies increased from 0% to 37.2%. No untoward effects on process or balancing measures occurred, with sustained improvement for 14 months.

Conclusion: Standardization efforts for patients with primary headaches led to improved use of evidence-based therapies and reduced nonstandard abortive therapies. This methodology also led to improved DHE use for migraine headache resistant to first-line therapies. We accomplished these results without increasing length of stay, admission, or return visits.

PubMed Disclaimer

Figures

Fig. 1.
Fig. 1.
KDD for standardization of acute primary headache in the PED. LOR, level of reliability.
Fig. 2.
Fig. 2.
Percent of patients presenting to the PED with primary headache who received evidence-based first-line therapies (P chart).
Fig. 3.
Fig. 3.
Percent of patients presenting to the PED with primary headache who received nonstandard abortive headache therapies (P chart).
Fig. 4.
Fig. 4.
Percent of patients who received DHE for refractory headache symptoms in the PED (P chart).
Fig. 5.
Fig. 5.
Percent of patients with order set used for headache management in the PED (P chart).
Fig. 6.
Fig. 6.
Percent of patients with primary headache receiving intravascular therapies within 90 minutes of arrival to the PED (P chart).
See this image and copyright information in PMC

References

    1. Conicella E, Raucci U, Vanacore N, et al. . The child with headache in a pediatric emergency department. Headache. 2008;48:1005–1011. - PubMed
    1. Zhang Y, Kong Q, Chen J, et al. . International classification of headache disorders 3rd edition beta-based field testing of vestibular migraine in China: demographic, clinical characteristics, audiometric findings and diagnosis statues. Cephalalgia. 2016;36:240–248. - PubMed
    1. International Headache Society. IHS Classification ICHD-3: Migraine. 2019. Available at https://ichd-3.org/1-migraine/1-1-migraine-without-aura/. Accessed June 11, 2020.
    1. Lewis DW. Pediatric migraine. Neurol Clin. 2009;27:481–501. - PubMed
    1. Deubner DC. An epidemiologic study of migraine and headache in 10-20 year olds. Headache. 1977;17:173–180. - PubMed