The use of intravenous fluids, ketorolac, dexamethasone, and the dopamine receptor antagonists (DRAs) prochlorperazine/metoclopramide has increased from 2000 to 2014 in the treatment of patients with migraine admitted to the emergency department (ED), according to a study in the American Journal of Emergency Medicine. During this same time period, the use of narcotics and discharge prescriptions for narcotics have decreased in this patient population, likely because of the increased use of nonnarcotic medications.
A total of 2,824,710 consecutive patients who were admitted to the ED between 1999 and 2014 were included in the analysis. Of these patients, 8046 (0.28%) were admitted to the ED for migraine. The investigators reviewed 290 medical charts of patients at the beginning (1999-2000) and end (2014) of the study period to compare the use rates of various treatment modalities in patients with migraines admitted to the ED. Medication groups included antihistamines and DRAs prochlorperazine/metoclopramide, parenteral narcotics, and oral narcotics. Additionally, the investigators reviewed differences in annual return rates in those who returned to the same ED within a 72-hour period between 1999 and 2000 and 2014.
The researchers reviewed 147 and 143 medical charts of patients with migraine admitted to the ED between 1999 and 2000 and 2014, respectively. From 1999 and 2000 to 2014, there was a significant increase in the use of DRAs (24% vs 83%, respectively; difference, 58%; 95% CI, 48%-66%), intravenous fluids (14% vs 88%, respectively; difference, 74%; 95% CI, 65%-81%), and ketorolac (5% vs 38%, respectively; difference, 34%; 95% CI, 25%-42%) and dexamethasone (0% vs 22%, respectively; difference, 22%; 95% CI, 15%-29%) in patients with migraine admitted to the ED. During the same time period, there was a decrease in narcotic use (80% vs 24%; difference, -56%; 95% CI, -45% to -64%) and discharge prescriptions (30% vs 8%; difference, -22%; 95% CI, -30% to -13%). Additionally, there was a decrease of 12% to 4% in the return rate from 1999 to 2000 to 2014, respectively (difference, 8%; 95% CI, 5%-11%).
Limitations of the analysis include its retrospective design as well as the inclusion of only 4 hospitals in the Northeast, which may reduce generalizability.
“Because this was a retrospective study, we cannot claim that change in treatments caused the decrease in revisit rates,” the investigators concluded. “Changes in other factors, such as access to primary care, could have also contributed.”
Ruzek M, Richman P, Eskin B, Allegra JR. ED treatment of migraine patients has changed [published online August 20, 2018]. Am J Emerg Med. doi: 10.1016/j.ajem.2018.08.051