Use of Narcotics for Migraine Treatment in the ED Has Dropped Significantly

Over the years, the treatment of migraine in the emergency department (ED) has changed significantly. According to a new study, from 1999-2000 to 2014, the use of IV fluids, dopaminergic receptor antagonists prochlorperazine/metoclopramide (DRA), ketorolac, and dexamethasone increased while the use of narcotics decreased. The study also found that, at discharge, prescriptions for oral narcotics decreased.

The study findings, published in the American Journal of Emergency Medicine, come at a time when the public and medical communities, as well as government agencies, are increasing efforts to lower narcotic dispensing in response to the opioid epidemic that continues to claim thousands of lives each year. Specifically in migraine, many nonopioid medications have been found to be effective as treatment in the ED.

“The goals of migraine treatments should be symptom relief with minimal side effects, maintenance of the treatment effect after discharge to prevent the need to return, and prevention o the inadvertent ‘side-effect’ of long-term drug dependence,” wrote the researchers of the study.

Based on the increasing evidence for efficacy of nonnarcotic treatments and risks of using narcotics, the researchers hypothesized that physicians in the ED have likely reduced the prescribing of these drugs in recent years.

Collecting and analyzing data from 4 New Jersey EDs, the researchers identified 2,824,710 visits, of which 8046 (.28%) were for migraine. They reviewed 290 charts (147 in 1999-2000 and 143 in 2014), making note of treatments administered during each visit.

From 1999-2000 to 2014, the use of IV fluids, DRA, ketorolac, and dexamethasone increased by 75%, 58%, 34%, and 22%, respectively. Meanwhile, parenteral narcotics given in the ED and narcotic prescriptions at discharge dropped by 56% and 22%, respectively. The use of antihistamines also dropped by 7% during the period.

During the study period, 624 patients revisited the ED within 72 hours. However, the revisit rate decreased from 12% in 1999-2000 to 4% in 2014. “We speculate that the decrease in revisit rates was due to use of different medications, although other factors such as changes in access to primary care physicians may have also contributed,” noted the researchers.

There was no significant difference in age and gender between patients at the beginning and the end of the study or between patients who did and did not revisit the ED.

Reference

Ruzek M, Richman P, Eskin B, et al. ED treatment of migraine patients has changed [published online August 20, 2018]. Am J Emerg Med. doi: https://doi.org/10.1016/j.ajem.2018.08.051.