EXECUTIVE SUMMARY

Although there is solid evidence to support how patients presenting with migraine headaches should be treated in the ED, studies show there is wide variation in the care that these patients receive. To reduce this variation, experts have unveiled guidelines based on a review of 68 randomized, controlled trials that looked at 28 injectable migraine medications.

  • Investigators did not present any A-level, or must-offer, recommendations, but four medications received B-level, or should-offer, recommendations.
  • The authors advised that intravenous metoclopramide and prochlorperazine, as well as subcutaneous sumatriptan, should be offered as a first-line treatment to adults who present to the ED with an acute migraine.
  • Investigators also advised that dexamethasone should be offered to these patients to prevent their acute headache from recurring over the short term.
  • Researchers noted that injectable morphine and hydromorphone should be avoided as a first-line therapy.

It is not unusual for head pain to become so severe or debilitating that it drives the sufferer to seek relief in the emergency setting. Experts note that headache is, in fact, the fifth most common reason for a visit to the ED, and most of these cases involve migraine headaches. Certainly, this is not news to front-line clinicians who see these types of patients on a daily basis. However, data show there is ample room for improvement in how these cases are managed.

For instance, in a recent review article on the management of adults with migraine in the emergency setting, the authors noted that there is wide variation in how patients who present to the ED with migraine are treated. Out of more than 1.2 million yearly visits to the ED for acute migraine, the investigators noted that more than 20 different drugs and drug combinations typically are prescribed.1

Further, and perhaps not surprisingly, patients who are treated in the ED for an acute migraine typically do not experience long-lasting results. The authors noted that clinical trial data show that only about one-quarter of these patients experience sustained relief following their ED visit, setting up the potential for repeat ED visits and continued suffering.

To obtain guidance on the way forward in treating migraine in the emergency setting, ED Management caught up with a headache specialist from the University of Miami Miller School of Medicine who sees patients with the most severe types of migraines, and an emergency medicine physician who is one of the authors of the review on management of acute migraine cited above.

Base Treatment on Evidence

Although roughly 12% of Americans suffer from migraines, medical scientists still lack a complete understanding of what a migraine is, observes Benjamin Friedman, MD, an emergency physician at Montefiore Medical Center in Bronx, New York, and a co-author of the recent review on management of migraine. “We still don’t understand the pathophysiology of what goes on during a migraine attack,” he explains. “But from an emergency perspective, I think we have seen a number of high-quality trials that have shaped how to treat migraine in the emergency setting.”

Friedman et al. set out to clarify for providers what the evidence suggests are the best options for treating patients who present with migraine, based on 68 randomized, controlled trials that looked at 28 injectable migraine medications. Although the authors did not present any A-level, or must-offer, recommendations, four medications received B-level, or should-offer, recommendations. “What a B-level recommendation means is that there is very strong evidence that these medications are effective; they are generally well-tolerated and they are superior to alternatives,” Friedman observes.

Specifically, the authors noted that intravenous metoclopramide and prochlorperazine and subcutaneous sumatriptan should be offered as a first-line treatment to adults who present to the ED with an acute migraine. In addition, the authors indicated that dexamethasone should be offered to these patients to prevent their acute headache from recurring, although Friedman clarifies that dexamethasone is effective for short-term prevention only.

“An acute migraine is a 72-hour process. An acute attack can recur within that 72-hour period, and so the preventive [care] we are giving is not to decrease the number of headaches a patient is having, it is to prevent the recurrence of a headache in the immediate aftermath of an ED visit,” he explains.

Largely Avoid Opiates

With regard to opiate medications, the authors were more circumspect. Pointing to a lack of evidence regarding efficacy and concerns about long-term complications, they suggested that injectable morphine and hydromorphone “are best avoided as a first-line therapy.”

Friedman stops short of saying that opiate drugs should never be used as a first-line therapy for migraine, instead emphasizing that physicians should make informed decisions. “There is a substantial evidence base for how to treat acute migraine. So if emergency physicians are actively choosing opioids preferentially because they have said that they have read through the literature and read about these medications, and they understand the side effects that come with them, and given all that, they choose opioids because they think opioids are the best for their patient, then that is a position that I can respect,” he explains. “But if this is not an informed decision, then I would say read the literature and understand a little bit more about these various medications.”

Although there is much discussion in the literature and elsewhere about the dangers of opioid prescribing, Friedman notes that the data are not clear about the efficacy of using opioids to treat migraine or about associations between opioids and so-called bounce-back headaches. “No one can point to a high-quality clinical trial and say that in this trial opioids were clearly shown to cause less effective headache treatment, more bounce-backs to the ED, or more abuse down the road,” he says. “There [are] a lot of lower quality data or correlative data where patients who got migraines and were treated with opioids in the ED were more likely to come back to the ED ... but it is unclear whether [these findings are valid] or not because they are not based on high-quality data. They are just associations that have been noticed.”

Consider Patient History

Teshamae Monteith, MD, FAHS, chief of the headache division in the department of neurology at the University of Miami Miller School of Medicine, agrees that there is no hard and fast rule that stipulates that opiates should never be used to treat migraine, but notes that nonopiate management is the preferable first-line treatment option. “The best way to treat the patient is with migraine-specific medications. These are triptan medications that can easily be used and might be helpful to patients with migraine if they come in early enough,” she says.

However, Monteith concurs that neuroleptics, such as metoclopramide and prochlorperazine, can be very useful in treating migraine attacks. When these drugs are used in combination with ketorolac, a nonsteroidal anti-inflammatory medication, and basic hydration, they can be very effective in migraine patients, she says.

In addition to avoiding opiates, Monteith recommends emergency providers stay clear of prescribing Fioricet, a medication which contains acetaminophen, butalbital, and caffeine. “These prescriptions are very easy to write in getting patients treated and out of the ED, but these drugs are associated with rebound headaches and medication overuse headaches,” she says. “Patients with migraines should have more migraine-specific care and less of the nonspecific care, which includes the opiates and Fioricet.”

Monteith advises that getting an accurate history from patients who present with migraine is very important because some migraines are caused by specific triggers that dictate different treatment strategies. “We know that menstrual migraines are associated with more severe attacks, longer-lasting attacks, and more difficult to treat attacks. So asking patients if they are on their menstrual period is very useful because the treatment option would be very different for that patient,” she explains.

Think About Future Attacks

Especially for cases in which patients repeatedly visit the ED with migraine attacks, emergency providers must think about longer-term solutions, Monteith observes. “I think reducing utilization is as important as treating that acute migraine,” she says. “Setting that patient up with education about prevention and abortive care is going to be really important, as well as prescribing migraine-specific treatments.”

If a migraine patient comes to the ED, Monteith advises providers to ask if the patient is taking a triptan medication. If the triptan is not effective, she says, the provider should find out what other triptans the patient has used. “You need to make sure they are hooked up with a neurologist. If you look back in the chart and see that they have come to the ED one or two times before, you might consider sending them to see a local headache specialist,” she says.

This step involves appropriate coordination of care, Monteith stresses, noting that headache specialists often are linked to infusion centers in which patients have access to more and better treatments than they would receive in an emergency setting. “Teaching patients that they don’t necessarily need to get their treatment in the ED is important,” she adds.

Friedman, who sees two or three patients with migraine on every shift he works in the ED, adds that migraine represents a spectrum. People presenting with mild migraines may be fine taking ibuprofen once in a while, he says. “At the other end of the spectrum are people with chronic migraine, which is having migraine on more days than not,” Friedman observes. “Certainly, repeat ED presentation for management of migraine is a marker of serious underlying disease, and these are patients who should probably be handled by specialty care.”

REFERENCE

  1. Orr S, Friedman B, Christie S, et al. Management of adults with acute migraine in the emergency department: The American Headache Society evidence assessment of parenteral pharmacotherapies. Headache 2016;56:911-940.

SOURCES

  • Benjamin Friedman, MD, Emergency Physician, Montefiore Medical Center, Bronx, New York. Email: bwfriedmanmd@gmail.com.
  • Teshamae Monteith, MD, FAHS, Chief, Headache Division, Department of Neurology, University of Miami Miller School of Medicine, Miami. Email: tmonteith@med.miami.edu.