Evaluation of the role of oxygen therapy in the treatment of patients presenting to the emergency department with primary headache accompanied by nausea and vomiting

Authors

Abstract

Aim It is crucial to treat patients presenting with headaches quickly and effectively, particularly in emergency services and outpatient clinics. Given the widespread use of analgesics in headache treatment, the aim of this study is to emphasize the importance of oxygen inhalation therapy to increase efficacy and reduce analgesic usage.
Material and Methods Data were collected prospectively from patients admitted to the emergency department with headache complaints between November 2016 and January 2017. Two randomized groups were formed: one group received only metoclopramide, while the other received metoclopramide with oxygen therapy. Both groups underwent numerical pain scoring based on gender, age, pain level, and accompanying photophobia or phonophobia at 20, 40, and 60 minutes, and the data were then analyzed.
Results Our study included 106 patients, with 53 receiving IV metoclopramide therapy. Oxygen inhalation therapy was administered to 3% of patients along with IV metoclopramide at a rate of 10 L/min via a diffuser mask. The median pain levels of patients in Group 2 were as follows: 20 minutes -5 ± 3.4, 40 minutes -2 ± 3.0, and 60 minutes -1 ± 2. Treatment success rates at 20 minutes were 3.8% in Group 1 and 18.9% in Group 2, increasing to 60.4% and 81.1% at 60 minutes, respectively. The median time to end pain was calculated as 40 minutes in the metoclopramide treatment group and 50 minutes in the group receiving oxygen therapy.
Conclusion The addition of oxygen to treatment has been shown to significantly increase treatment efficacy and shorten patient pain relief time. Oxygen inhalation has shortened the duration of patients’ pain and played an active role in early patient discharge.

Keywords

Introduction

Headache is defined as any pain localized in the region of the head. These pains are classified into three separate groups according to the international classification. These include primary headaches, whose etiology is not defined; secondary headaches, which have an identifiable cause such as neuropathies, and other types of headaches ¹. The causes of primary headaches include migraines, cluster headaches, tension-type headaches, trigeminal autonomic cephalalgias, and other primary headaches, all of which constitute a significant health problem in society ². According to current data, the lifetime prevalence of headaches is 96%, with variations depending on the type of headache, and it is most frequently observed in females. Tension-type headaches are the most prevalent, with a prevalence rate of 40% ³.
Due to common primary headache causes such as tension-type headaches and migraines, patients often require excessive use of painkillers. This condition also leads to a lower quality of life, and disability, and the tests and examinations used in its diagnosis cause an economic burden at both individual and societal levels. In the European Union, the total annual cost of headaches among adults aged 18 to 65 is estimated to be 173 billion euros ^4,5. Moreover, according to the Global Burden of Disease study, headache is the second most common cause of years lived with morbidity ^5,6. Accurate diagnosis and appropriate treatment can reduce the impact of headaches on patients and improve their quality of life. Additionally, it will prevent economic loss by reducing the number of hospital visits and unnecessary medication use ^5,7.
In daily practice, a wide variety of prescription medications can be administered to patients presenting with headaches, but these medications may be ineffective or contraindicated in a significant number of cases. For such a complex pathology that affects patients in many areas, it is beneficial to plan both acute and prophylactic treatments. Moreover, non-pharmacological treatments have recently gained popularity in headache management. These treatments can be beneficial, can be combined with conventional treatments when necessary, and can serve as alternative therapies ⁸.
Oxygen therapy is the first-line acute attack treatment recommended in cluster headache guidelines in Europe and America ^9,10. It is frequently preferred as an alternative treatment option due to its lower cost, fewer side effects, and suitability for patients for whom triptans are contraindicated, such as those with coronary artery disease ¹¹. The exact mechanism underlying the effects of oxygen therapy on headache disorders is unclear. Proposed mechanisms include the inhibition of the cranial parasympathetic pathway or the trigemino-autonomic reflex, modulation of neurotransmitters or neuropeptides, and cerebral artery vasoconstriction ¹².
In our study, we aim to evaluate the effect of oxygen therapy in patients presenting to the emergency department with primary headaches accompanied by nausea and vomiting, and to contribute to the literature with the data obtained.

Materials and Methods

Study designOur study was conducted in the emergency department of a tertiary education and research hospital. The hospital has a capacity of 688 beds and serves 450 emergency department patients daily. Necessary permissions were obtained before commencing the study. This is a single-center, prospective, observational study conducted in the emergency department of a tertiary education and research hospital. The study took place between March 1, 2017, and June 1, 2017.
Study Settings and PopulationThe study included patients who presented to our hospital’s emergency department with primary headaches accompanied by nausea and vomiting between November 1, 2016, and January 1, 2017, and who met the inclusion criteria.
The patients who participated in the study were adults diagnosed with primary headaches. The diagnoses of primary headaches were made by a neurology specialist with at least three years of experience in the field. Diagnoses were based on patients’ medical histories, physical examination findings, imaging tests, and clinical evaluations from previous headache consultations. Patients diagnosed with conditions other than primary headaches, those with head trauma, a history of intracranial mass, pregnant patients, those who did not consent to participate, or those who wished to withdraw from the study were excluded.
The pain levels of the included patients were assessed using a numerical pain scale, and the determined scores were recorded on a pre-prepared study form. Additionally, the patients’ pain levels were reassessed and recorded at 0, 20, and 40 minutes after treatment.
Study ProtocolThe data for the cases included in the study were obtained from patient files and the hospital’s automation system. Additionally, the medical histories and clinical data of the cases were recorded on a pre-prepared study form. These data were then transferred to a digital format.
The admission times, vital parameters, the number of symptoms accompanying the headache, and the pain levels according to the Numerical Pain Rating Scale (NPRS) and Visual Analog Scale (VAS) at 0, 20, 40, and 60 minutes were recorded on the form for the patients included in the study.
MeasurementsThe medical treatment method to be applied to the patients was chosen by the doctor using the shuffle bag method. In one group of patients, 10 mg of metoclopramide was administered intravenously as an infusion in 150 cc of isotonic liquid over 15-20 minutes (Metoclopramide treatment group - MTP group). In another group, 10 mg of metoclopramide was administered intravenously in 150 cc of isotonic liquid over 15-20 minutes, along with 10 L/min of oxygen therapy via a diffuser mask for 60 minutes (Metoclopramide + O2 treatment group - MTP+O2 group).
During the treatment, the patients’ pain levels were assessed at the 20th, 40th, and 60th minutes and recorded in the data collection form. If the pain resolved earlier within the treatment duration, the time when the pain subsided was recorded in the data recording form.
Statistical analysis
SPSS 22.0 and PAST 3 programs were used to analyze the data we obtained in our study. The suitability of univariate data for normal distribution was evaluated with the Shapiro-Wilk test. The Independent Samples T-test was used to compare the quantitative data of two independent groups and Mann-Whitney U test was used to compare the average data of the two groups. To compare the quantitative variables of the dependent quantitative variables with each other, Friedman’s Two-Way test was evaluated with Monte Carlo simulation methods, while Dunn’s test was used for post hoc analysis. Pearson Chi-Squared and Fisher Exact tests were used to compare categorical binary variables. Quantitative variables were shown as mean ± std. (standard deviation), median ± IQR (interquartile Range) and median Range (maximum-minimum), and categorical variables were shown as n (%) in the tables.
Variables were examined at a 95% confidence level and p-value was considered as <0.05.
Findings
In the study, 68.9% of the 106 patients (n=73) were female, and the mean age was 40.11 ± 13.70 years. In the MTP group, 66% of the 53 patients (n=35) were female, with a mean age of 39.62 ± 12.73 years; in the MTP+O2 group, 71.7% of the 53 patients (n=38) were female, with a mean age of 39.62 ± 12.73 years. Photophobia was observed in 15% (n=16) of cases, phonophobia in 13.2% (n=14), and both photophobia and phonophobia were found together in 19.8% of the patients (n=21).
At the time of hospital admission (0 min), the median (±IQR) pain level for all patients was 8 ± 2. For the MTP group, the median (±IQR) pain level was 9 ± 2, while for the MTP+O2 group, it was 8 ± 3. The median ± IQR values of the patients’ pain levels at the 20th, 40th, and 60th minutes during treatment are presented in Table 1.
When examining the relationship between pain levels and medical treatments at the 20th, 40th, and 60th minutes, it was observed that the pain levels in the MTP+O2 group were statistically significantly decreased compared to the MTP group at all time points (p20min = 0.012, p40min = 0.007, and p60min = 0.014) (Table 1).
When the pain levels of the patients were assessed at the 20th, 40th, and 60th minutes; if “0” was marked on the NPRS scale, the treatment was considered successful, and the pain was completely gone; in other values, it was accepted that the pain continued, and the treatment was unsuccessful. The data were handled from this point of view, and the effectiveness of MTP and MTP+O2 group treatments was compared. It was observed that there was a statistically significant difference between the MTP and MTP+O2 groups at all stated times (Table 2, Graphic 1).
In the study, the treatment of patients whose headaches resolved within 60 minutes was considered successful. Accordingly, the treatment was successful in 60.3% (n=32) of the patients who received MTP treatment and 81.1% (n=43) of the patients who received MTP+O2 treatment. In light of these data, it was determined that adding O2 to the treatment statistically increased its success. (p=0.032). Additionally, when the average duration of pain relief was examined in these patients, the mean duration of pain relief was 50 minutes (20-60 minutes) in patients who received only MTP treatment, while it was 40 minutes (16-60 minutes) for those who received MTP+O2 treatment. It was observed that even adding only O2 to the treatment caused a statistically significant decrease in the total duration of pain relief (p=0.020) (Table 3).
Ethical Approval
This study was approved by the Ethics Committee of Bozyaka Training and Research hospital (Date:2014-10-15, No: 2019-GOKAE-0931). Additionally, clinical approval was obtained from the Department of Emergency Medicine.
Our study was conducted in accordance with the 1964 Declaration of Helsinki and Good Clinical Practice guidelines. Informed consent was obtained from each participant or their legal guardian, and these consents were numbered and archived.

Results

In our study, the addition of oxygen therapy to the treatment of patients presenting with primary headaches was observed to lead to a rapid decrease in pain scale. In this context, it was observed that oxygen therapy in patients with primary headaches shortened the duration of medical treatment and thus reduced the exposure time to unwanted effects of medical agents. Due to both shortening the exposure time and preventing economic losses, we believe that the addition of oxygen to the treatment in patients presenting with primary headaches is beneficial.”

Discussion

In the literature, alternative treatment procedures or combined treatment protocols, in addition to medical treatment, have been researched and continue to be investigated for primary headache cases. Oxygen therapy is already known for the treatment of cluster headaches. It is well-known that in patients with cluster headaches, oxygen therapy is the first-line treatment in the guidelines of Europe and America ^9,10. In a study by Cho et al. on patients with cluster headaches, one group received zolmitriptan, while another group received oxygen therapy. It was found that patient satisfaction was significantly higher in the group receiving oxygen therapy compared to the group receiving zolmitriptan. Additionally, in the same study, 57% of patients who received 30 minutes of oxygen therapy reported no longer needing analgesics ¹³.
In a study by Cohen et al., patients with headaches were divided into two groups: one group received room air, and the other received oxygen therapy. The treatment was considered successful if the patient’s pain was alleviated. At the 15th minute, treatment success was 20% in the air group and 68% in the oxygen group; at the 20th minute, 30% in the air group and 81% in the oxygen group; at the 30th minute, 38% in the air group and 85% in the oxygen group; and at the 60th minute, 59% in the air group and 92% in the oxygen group ¹¹. Özkurt et al. found that treatment success was 80% in the group receiving oxygen ¹⁴. In a study by Singhal et al., it was reported that oxygen therapy led to a rapid and effective reduction in headache symptoms in migraine patients ¹⁵. Another systematic study investigated the effectiveness of oxygen therapy compared to placebo in migraine patients and showed that oxygen therapy significantly reduced symptoms compared to placebo ^16,17. Furthermore, Saeedi et al. conducted a study on primary headaches using three different oxygen delivery methods and found statistically significant improvement with all three methods ¹⁸. In a study by Soltani et al. comparing metoclopramide and ketorolac in patients with primary headaches, no superiority between the drugs was demonstrated ¹⁹.
In our study, we found that adding oxygen to MTP as a combined treatment for headache complaints resulted in significant differences in both treatment success and pain relief time compared to patients who received only MTP, with pain resolving more quickly. In this context, our study demonstrated that oxygen therapy can be an economical and rapid treatment method for patients with primary headaches.
Oxygen therapy is routinely used in the treatment of cluster headaches. Nowadays, it is suggested that high-flow oxygen devices may effectively treat cluster headaches and may even be preferable to sumatriptan, which has FDA approval for use in this condition, due to potentially fewer side effects ²⁰. Currently, the use of oxygen, including high-flow oxygen, is recommended in the treatment of all types of primary headaches ²¹. Similarly, based on a study by Shah et al., oxygen therapy is recommended for patients with migraines ²².
In the literature, it is reported that primary headaches, although varying by type, predominantly affect females. Mihaiu et al. reported that females were the majority with a mean age of 34.31 years in their study on patients with primary headaches ²³. Wells et al. noted that primary headaches are more prevalent in females and are commonly seen in younger patients ²⁴. Mavioğlu et al. found that 85% of cases were female, with a mean age of 39.62 ± 12.73 years ²⁵. Özkurt et al. observed a female predominance in both groups in their study, with a mean age of 39.42 ± 13.79 years ¹⁴. In our study, 68.9% of cases were female, with a mean age of 40.11 ± 13.70 years. Thus, our study aligns with existing literature regarding age and gender distribution in primary headaches.

Limitations

Unfortunately, our study has certain limitations. Firstly, we acknowledge the single-center nature of our study and the relatively small sample size. Additionally, pain scores were evaluated based on patient-reported outcomes, which makes them subjectively patient-specific. However, we believe these limitations do not significantly impact the study outcomes. To generalize our findings, multicenter studies with larger patient cohorts are needed.

Declarations

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About This Article

Received:

May 7, 2024

Accepted:

July 9, 2024

Published Online:

March 11, 2026