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For Your Patients-Migraine
Fewer Migraine Patients Receiving Opioids at Hospitals, Revisits Down

ARTICLE IN BRIEF

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DR. FREDERICK FREITAG: “I would say that opioid use in acute migraine is down quite a bit. Our people have recognized for a while now that there are other treatments, and we only use opioids as a last resort in patients with severe migraine who are resistant to multiple drugs.”

Researchers report that emergency departments (EDs) are moving away from prescribing opioids and other narcotic prescriptions for migraine patients, and the revisits to the ED for migraine have also declined.

A retrospective chart review of emergency department (ED) records at four Northeastern hospitals found a significant trend away from using opioid medications to treat acute migraines since 2000, as well as a decrease in ED revisits.

The study found that while 80 percent of migraine patients received parenteral or oral narcotics at the ED in 1990-2000, the rate fell to just 24 percent in 2014. This was matched with a decline in narcotic prescriptions from 30 percent to 8 percent. The number of ED revisits for migraine likewise fell to 7 percent.

The investigators said that the study is the first to document a decline in both narcotic treatment in EDs and fewer revisits among migraine patients.

STUDY DETAILS

The researchers recorded ED use of narcotics, antihistamines, and the dopaminergic receptor antagonists (DRA) prochlorperazine/metoclopramide at four New Jersey suburban EDs with annual visits ranging from 27,000 to 84,000.

The investigators were led by John R Allegra, MD, PhD, research director of emergency medicine at Morristown Medical Center in New Jersey, and an assistant clinical professor of emergency medicine at the Icahn School of Medicine at Mount Sinai in New York City. The findings were published online ahead of print on August 20 by the American Journal of Emergency Medicine.

Because it was a retrospective study, the researchers could not say definitively whether or not the changes in treatments might have been responsible for the decrease in revisit rates. They also said that it is not known whether or not their findings can be generalized to the rest of the country.

“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,” the researchers wrote.

For analysis purposes, they only analyzed treatments given in at least 20 percent of the visits in one of the two time periods and calculated the percentage of migraine patients given each treatment in each time frame.

Of the 8,046 migraine patients, 624 revisited the ED within 72 hours, a decrease from 12 percent to 4 percent from 2000 to 2014.

PRIOR STUDIES

The new findings are in contrast to several earlier studies that have reported significant increases in ED use of opioids in migraine patients, although these studies were in other regions of the US.

One study that used National Hospital Ambulatory Medical Care Survey data from 1998 and 2010 found opioid use increased slightly from 1998 to 2010 and, in spite of recommendations to the contrary, opioids were still used in 2010 in more than half of all ED visits for migraine.

Another research paper that reviewed the same database found that the number of ED patients who received opioids jumped from 21 percent in 2001 to 31 percent in 2010, a relative increase of 49 percent.

These two studies however used data using different time periods and geographic areas.

A third study examined revisit rates by children with migraines, a retrospective cohort study from 2009 to 2012. It found that a majority of these young patients were successfully discharged and only 5.5 percent revisited a hospital within three days. Unlike the current study, this paper did not report revisit rates per year.

EXPERT COMMENTARY

Frederick Freitag, DO, associate professor of neurology at the Medical College of Wisconsin, said he too has noticed a decline.

“I would say that opioid use in acute migraine is down quite a bit. Our people have recognized for a while now that there are other treatments, and we only use opioids as a last resort in patients with severe migraine who are resistant to multiple drugs,” he told Neurology Today.

“Today we have a range of options, including medical procedures and new treatments that are usually effective.”

In addition to more traditional treatments with dopaminergic receptor antagonists, serotonin antagonists like sumatriptan and dihydroergotamine injections can also help patients. Among other alternatives, he said there has been a resurgence in the use of greater occipital nerve block (GONB); intranasally injecting lidocaine, bupivacaine, or both. Newer catheter devices like Tx360 have made this even easier, Dr. Freitag said, noting that most patients obtain very rapid relief from symptoms that can last for hours.

The Tx360 device was approved in 2010 for the delivery of small amounts of anesthetic fluid directly through the nasal path to areas such as the superior or inferior turbinate and the sphenopalatine foramen. “This has radically improved comfort for patients and ease of delivery for physicians,” he said.

Richard B. Lipton, MD, FAAN, the Edwin S. Lowe professor and vice chair of neurology at Albert Einstein College of Medicine in New York City, told Neurology Today that the headache medicine community has been at the forefront in reducing opioid use.

“We have avoided opioid medications for a very long time in people with migraine,” he said. “A 2017 randomized trial found the dopamine blocker, IV prochlorperazine, is more effective than the potent narcotic, hydromorphone in the treatment of migraine in the ED. In patients who do not get the full benefits they need from dopamine blockade greater occipital nerve blocks are effective.”

Dr. Lipton, who also serves as director of the Montefiore Headache Center, in the Bronx, said the trend away from narcotic treatment for severe headaches started in the 1980s with the recognition that opioid analgesics can make migraine worse in the long run.

He emphasized that he is not opposed to opioid use when appropriate, for example in patients with cancer. But, he said, opioids should not be a front-line remedy for migraine.

“Opioids may have a role in migraine when other treatments fail or are contraindicated, but this group is less than 2 percent of people with migraine. There are almost always other treatments that are more effective and safer. The new study showed a decline in opioid use for migraine in the ED to about one in four, and that represents real progress. But most patients receiving opioids in the ED for migraine would be better served by other classes of medication.”

Dr. Lipton pointed to a 2015 study conducted by his colleagues at Albert Einstein in which data from the National Hospital Ambulatory Medical Care Survey in 1998 and 2010 were compared. It showed that 50 percent of all migraine patients who visited emergency departments in 2010 received narcotic medications despite recommendations to the contrary. Moreover, they reported that opioid use was independently associated with prior visits to the same emergency department in the prior 12 months.

“I think the rate of use in the new study is probably better than the national rate,” Dr. Lipton said.

BY THE NUMBERS: MIGRAINE IN THE ED

  • 2,824,710 ED visits in the database, 8,046 of which were for migraine
  • 74 percent increase in the use of IV fluids by 2014
  • 34 percent increase in use of ketorolac by 2014
  • 22 percent increase in use of dexamethasone by 2014
  • 56 percent significant decrease in parenteral narcotics at discharge
  • 22 percent decrease in oral narcotics at discharge

GREATER OCCIPITAL NERVE BLOCK TRIAL FOR HEADACHE-FREE STATUS

Preliminary results from a randomized clinical trial that was halted early due to low enrollment found that performing a bilateral greater occipital nerve block (GONB) with bupivacaine helped 30 percent of migraine patients with headache achieve headache-free status after standard treatment with intravenous metoclopramide.

Because there is no randomized efficacy data on the indication, researchers led by Benjamin W. Friedman, MD, of the department of emergency medicine at Albert Einstein College of Medicine, Montefiore Health System, Bronx, NY, compared GONB against sham injection in patients at two urban hospital EDs to determine if treatment might help when moderate or severe headache is not resolved despite standard treatment with intravenous metoclopramide. The findings were published August 25 in Headache.

The primary outcome was complete headache freedom 30 minutes after the injection. An important secondary outcome was sustained headache relief, defined as achieving a headache level of mild or none in the ED and maintaining a level of mild or none without the use of any additional headache medication for 48 hours.

The study was conducted over 31 months in 28 patients, 15 of whom were given sham injection and 13 who received GONB. Headache freedom at 30 minutes was achieved in 4 of the 13 patients in the treatment arm but none in the placebo arm, and 3 treated patients reported being headache-free at 48 hours, also compared to none in the sham patients.

The researchers concluded that despite being underpowered, the results suggested that GONB may be an effective treatment for such patients.

LINK UP FOR MORE INFORMATION:

• Ruzek M, Richman P, Eskin B, Allegra JR. ED treatment of migraine patients has changed https://www.ajemjournal.com/article/S0735-6757(18)30688-0/pdf. Am J Emerg Med 2018; Epub 2018 Aug 20.
    • Friedman BW, Irizarry E, Solorzano C, et al. Randomized study of IV prochlorperazine plus diphenhydramine vs IV hydromorphone for migraine http://n.neurology.org/content/89/20/2075. Neurology 2017; 89(20):2075–2082.
      • Friedman BW, Mohamed S, Robbins MS, et al. A randomized, sham-controlled trial of bilateral greater occipital nerve blocks with bupivacaine for acute migraine patients refractory to standard emergency department treatment with metoclopramide https://onlinelibrary.wiley.com/doi/abs/10.1111/head.13395. Headache 2018; Epub 2018 Aug 25.
        • Friedman BW, West J, Vinson DR, et al. Current management of migraine in the US emergency departments: An analysis of the National Hospital Ambulatory Medical Care Survey http://journals.sagepub.com/doi/abs/10.1177/0333102414539055. Cephalalgia 2015; 35(4):301–309.
          • Mazer-Amirshahi M, Mullins PM, Rasooly I, et al. Rising opioid prescribing in adult US emergency department visits: 2001-2010 https://onlinelibrary.wiley.com/doi/abs/10.1111/acem.12328. Acad Emerg Med 2014; 21(3):236–243.