Abstract
Migraine is an exceedingly common chronic condition in both adult and paediatric populations. Many patients with migraine headache manage symptoms and exacerbations with simple medical management, rest and without the need to access additional health services. At times when interventions at home fail, patients with moderate–severe migraines present to the Emergency Department (ED) for care. For example, 7% of Americans with migraine headaches report using the ED or Urgent Care Center for treatment of severe headaches within the previous 12 months (1). Moreover, in the USA evidence suggests that headaches account for approximately 2.2% of annual ED visits (2).
Patients who present to the ED with migraine exacerbations can be treated with a myriad of agents and it is not surprising that substantial practice variation among and within EDs has been documented (3–5). For example, previous research shows that 20 disparate parental agents have been used to treat acute migraine in US EDs in the past (2). In part, this may be due to the fact that the literature is confusing and expansive and clarity has yet to emerge. For example, a recent systematic review produced by an evidence-based practice centre and sponsored by the Agency for Health Care Research and Quality (AHRQ) identified 69 controlled clinical trials involving nine classes of drugs addressing the acute treatment of migraine in adults presenting to the ED (6). These trials compared active interventions with placebo or, in some studies, with an active comparator and were designed to report pain relief in the ED and, in some cases, headache recurrence. Given the wide range of comparators available to the investigator group, a mixed treatment analysis/network meta-analysis was conducted. The results demonstrated that combination therapy (e.g. dihydroergotamine (DHE) added to other neuroleptics or metoclopramide) and neuroleptic mono-therapy were the most effective treatments. Mono-therapy treatments with metoclopramide, ketorolac or opioids were second-line agents and third-line agents included medications such as DHE. The review was limited to pharmacological treatments and failed to address any potentially efficacious non-pharmacological treatments (e.g. rapid assessment, dark room, quiet treatment space separated from the chaos of most EDs). Moreover, it found no evidence for certain combinations in common use and it is known that other treatments prescribed in the ED setting have no trials associated with them (e.g. fluid boluses). From these results, however, clinicians could easily develop an evidence-based approach to migraine management in EDs.
Despite the available evidence, there are some drawbacks associated with several of the agents that are commonly used for treatment of migraines in the ED. Once again, the AHRQ report identified metoclopramide and neuroleptic agents as common causes of akathisia, a disturbing although self-limited adverse event associated with their administration (6). In addition, sedation is a common side effect from narcotics and some anti-emetic agents. Moreover, the older neuroleptics caused significant hypotension and have largely fallen from favour. Finally, agents such as opioids, particularly meperidine, have been shown to be highly addictive and increase relapse after discharge (3). Clearly, clinicians treating adults with migraine must weigh the benefits and risks of treatment when considering options in the ED setting.
The picture in paediatric EDs is similar with regard to practice variation; however, the evidence supporting interventions to treat migraine in the paediatric population is essentially non-existent. There is one randomized controlled trial of interventions in the acute setting showing that prochlorperazine is more efficacious than ketorolac. The overall use of opioids, however, appears to be lower in children (4). From both retrospective and prospective chart reviews in paediatric EDs, physicians appear to employ evidence from the adult literature, particularly for adolescent patients.
The article by Friedman and colleagues (7) is an update of previous research using the National Hospital Ambulatory Medical Care Survey database (5). In this research, sentinel sites across the USA that are representative of the entire emergency population have been used to reflect practice treating both pediatric and adult patients. In this update of migraine visits to US EDs, the rate of presentation and the use of opioids (59% of all visits) have remained reasonably stable. Despite the existence of this large volume of evidence and a large number of systematic reviews in this field, it is surprising and disappointing to see that the use of narcotic agents remains high. This is not a situation that is confined to the USA, as Canadian sites have been shown to employ similar treatment strategies (3). This new evidence does, however, demonstrate some encouraging findings, including the replacement of meperidine with oral opioid agents and the use of more evidence-based options such as anti-emetics, non-steroidal anti-inflammatory agents and neuroleptics. Nonetheless, the replacement of meperidine with other narcotics as first-line agents in migraine headache therapy does not conform to evidence-based care and reflects the need for wider knowledge translation of current evidence.
The results summarized by Friedman et al. are an important step required to encourage clinicians, administrators and policy makers to explore interventions and strategies to increase the use of evidence-based care for patients with migraine seen in the acute care setting. One strategy may be to abolish the use of meperidine in the ED setting, which would increase the use of alternative analgesic agents. Another alternative is to translate evidence-based summaries (8) into electronic and paper-based clinical practice guidelines in the acute setting. Finally, an inclusion of non-narcotic agents as quality markers for individual physician and ED report cards may facilitate the selection of more appropriate anti-migraine agents increasingly over time.
Finally, the prevention of future headaches is an important consideration in the ED. The best available evidence indicates that intravenous dexamethasone is an effective alternative for some patients (9). Given the frequency of presentations and the side effects associated with repeated short-term use of dexamethasone, it appears prudent to provide some recommendations on the restricted use of this agent. For example, subgroup analysis from one clinical trial found that patients who do not achieve complete pain relief following their ED management and/or those who report prolonged headache prior to ED presentation are most likely to benefit from the administration of these potent anti-inflammatory agents (10). It would appear reasonable to require that the guidelines described above include these types of recommendations.
Overall, both paediatric and adult migraine sufferers requiring treatment in the ED warrant evidence-based care for their immediate headache relief, consideration of preventive strategies to abort a future sub-acute relapse and appropriate referral to a specialist for chronic pain relief when presenting frequently in the ED setting. We now have the evidence upon which to improve care and it is up to those of us in the ED setting to examine innovative and effective ways of changing practice. Let’s not wait another 10 years!