Pharmacologic Management of Migraine in the ED: Opioid Use Decreased From 2010 to 2017

New findings published in the American Journal of Emergency Medicine indicate that, for emergency department (ED) visits for migraine between 2010 and 2017, opioid prescriptions decreased and administration of guideline-recommended treatments increased over the course of the study period.

The authors of the study arrived at their conclusion following an analysis of ED visits (N = 1846; 1.2 million ED visits per year in the United States) made by patients with a diagnosis of migraine upon discharge. Data were obtained from 2010-2017 National Hospital Ambulatory Medical Care Survey datasets. The Rao-Scott chi-squared test was used to compare the frequency of drug prescription throughout the study period. Weighted multivariable logistic regression was used to determine adjusted odds ratios of opioid treatment between 2010 and 2017, with age, sex, race/ethnicity, and pain score, among other factors, as predictor variables.

Specifically, the results of the study indicated that the prescription of opioids had decreased nearly 10% per year from 2010 to 2017. Parenteral opioids were prescribed in 49% of visits and 28% of visits in 2010 and 2017, respectively. Metoclopramide and ketorolac prescriptions increased throughout the study period, increasing between 2015 to 2017 compared with 2010.

Factors associated with increased odds of opioid treatment for all years in the study included older age, female sex, higher pain score, white race, and Medicare or private insurance as the main anticipated payment source.

NLN discussed these findings and their implications further with lead author Philip Wang, with the Cleveland Clinic Lerner College of Medicine of Case Western Reserve University in Cleveland, Ohio.

NLN: You and your colleagues noted that guidelines recommend a wide variety of medications to manage migraine in the ED. Based on your findings, how closely were these guidelines followed during the study period, especially regarding opioid prescription?

Mr Wang: What prompted Michael P. Phelan, MD, associate professor at the Cleveland Clinic Lerner College of Medicine at Case Western Reserve University, and me to conduct this study was a 2015 report published in Cephalalgia by Friedman et al, stating that nearly half (49%) of all patients who visited the ED with migraine in 2010 had received an opioid medication as part of their treatment. We were really surprised, since all of the guidelines we read mentioned that opioids were contraindicated because they have been shown to lead to repeat visits, longer visit times, and decreased sensitivity to more efficacious medications.

Especially given the current climate surrounding the opioid crisis, we were curious to see if these rates had decreased since 2010. We found that by 2015 to 2017, opioid administration had decreased, occurring in 28% of visits. While this decrease was excellent to see, this finding indicates that there is still room for improvement.

NLN: You and your colleagues found that the use of intravenous opioids had decreased and the use of ketorolac and metoclopramide had increased during the study period. Could you discuss the significance of these findings in more detail?

Mr Wang: Nonsteroidal anti-inflammatory drugs, such as ketorolac, and anti-dopaminergic anti-emetics, such as metoclopramide, are first-line agents for the management of migraine in the ED. We believe the fact that ED clinicians are electing to use ketorolac and metoclopramide more often and opioids less often represents greater adherence to guidelines.

NLN: Were all of these findings anticipated, or did any of them surprise you?

Mr Wang: We were surprised about a few of the factors that ended up leading to significantly higher odds of patients receiving opioids during their ED visit. A few of these factors, such as the racial, insurance, and pain score differences in opioid administration, have been previously described in the literature. However, we were surprised to see older age and female sex being associated with opioid administration, as these factors were less well described in the literature.

NLN: What areas of future research are still needed in this field?

Mr Wang: One area of research in which we are interested includes factors that affect follow-up after migraine management in the ED. After the initial ED evaluation, most migraine headache exacerbations can often be managed by primary care physicians or headache specialists/clinics. While the ED remains available for anyone suffering from acute, intractable migraine pain, we would be interested in identifying which patients and which interventions can increase the patients’ likelihood of receiving follow-up in a more appropriate clinical setting.

NLN: What key takeaways about this topic do you hope to leave with health care professionals?

Mr Wang: One of the key takeaways of our study is that current guidelines do not recommend opioids for the management of migraine headache in the ED. However, they recommend various other medications, including ketorolac and metoclopramide. Between 2010 and 2017, the use of IV opioids for migraine-related ED visits decreased, but there is still room for improvement. Finally, risk factors for higher odds of IV opioid administration in the ED included sex, race, and age.

—Christina Vogt

Wang PR, Lopez R, Seballos SS, Campbell MJ, Udeh BL, Phelan MP. Management of migraine in the emergency department: Findings from the 2010–2017 National Hospital Ambulatory Medical Care Surveys. Am J Emerg Med. 2021;41:40-45. doi:10.1016/j.ajem.2020.12.056