Acute Migraine

Migraines Are a Very Common Condition and Can Be Severely Debilitating

Migraines are a very common condition, with 15.3% of Americans aged 18 years or older reporting a migraine or severe headache in the previous 3 months,[1] a figure that has remained stable for almost two decades. Migraines can be severely debilitating and are considered one of the main causes of disability worldwide.[2] In one study among patients with migraines in the United States, more than half reported severe impairment in activity, the need for bed rest, and/or reduced work or school productivity due to migraines.[3]

Acute Migraines are Often Treated in the ED Setting

In the Emergency Department (ED) setting, headaches overall account for about 3% of all ED visits annually in the United States.[1] Use of opioids in the ED to treat this condition has been associated with increased risk of revisits, hospital admissions, and increased ED length of stay.[4] Despite published guidelines recommending non-opioid treatments for acute migraines, opioids were administered for adults presenting with migraines in over half of ED visits across age groups.[5],[6] Furthermore, one study found that 23% of adolescents and young adults who presented to the ED with a migraine received an opioid prescription,[5] exposing this younger cohort to opioids with potential long-term effects. Another study examining 2017 medical claims data among privately insured patients noted that opioid prescriptions linked to medical encounters for acute migraine were written for a median of 7 days (interquartile range 4-20 days) for a median daily dosage of 22.5 MMEpdf icon.[7]

3 months 15 percent graph

Migraines are common. Over 15% of Americans aged 18 years or older report having a migraine or severe headache in the last 3 months.

23 percent graph

23% of adolescents and young adults who visited an Emergency Department with a migraine received an opioid prescription.

Treatment Recommendations

  • “The specific medications – triptans (almotriptan, eletriptan, frovatriptan, naratriptan, rizatriptan, sumatriptan [oral, nasal spray, injectable, transcutaneous patch], zolmitriptan [oral and nasal spray]) and dihydroergotamine (nasal spray, inhaler) are effective (Level A).
  • Effective non-specific medications include acetaminophen, nonsteroidal anti‐inflammatory drugs (aspirin, diclofenac, ibuprofen, and naproxen), opioids (butorphanol nasal spray), sumatriptan/naproxen, and the combination of acetaminophen/aspirin/caffeine (Level A).
  • There are many acute migraine treatments for which evidence supports efficacy. Clinicians must consider medication efficacy, potential side effects, and potential medication‐related adverse events when prescribing acute medications for migraine. Although opioids, such as butorphanol, codeine/acetaminophen, and tramadol/acetaminophen, are probably effective, they are not recommended for regular use.”
  • “Because of lack of evidence demonstrating efficacy and concern about sub-acute or long-term sequelae, injectable morphine and hydromorphone are best avoided as first-line therapy.
  • Intravenous metoclopramide and prochlorperazine, and subcutaneous sumatriptan should be offered to eligible adults who present to an ED with acute migraine.”

[1] Burch R, Rizzoli P, Loder E. The Prevalence and Impact of Migraine and Severe Headache in the United States: Figures and Trends From Government Health Studies.external icon Headache. 2018 Apr;58(4):496-505.

[2] GBD 2016 Headache Collaborators. Global, Regional, and National Burden of Migraine and Tension-Type Headache, 1990-2016: a Systematic Analysis for the Global Burden of Disease Study 2016. Lancet Neurol. 2018 Nov;17(11):954-976

[3] Lipton RB, Stewart WF, Diamond S et al. Prevalence and Burden of Migraine in the United States: Data from the American Migraine Study II. Headache. 2001 Jul-Aug;41(7):646-57.

[4] Miller J, Koons L, Longyhore D. Opioid Free Treatment Algorithm for ED Headache Management: Effect on Revisit Rate. Am J Emerg Med. 2019 Apr 27

[5] Connelly M, Glynn EF, Hoffman MA, Bickel J. Rates and Predictors of Using Opioids in the Emergency Department to Treat Migraine in Adolescents and Young Adults. Pediatr Emerg Care. 2019 Jun 22.

[6] Young N, Silverman D, Bradford H, Finkelstein J. Multicenter Prevalence of Opioid Medication Use as Abortive Therapy in the ED Treatment of Migraine Headaches. Am J Emerg Med. 2017 Dec;35(12):1845-1849.

[7] Mikosz CA, Zhang K, Haegerich T, Xu L, Losby JL, Greenspan A, Baldwin G, Dowell D. Indication-Specific Opioid Prescribing for US Patients with Medicaid or Private Insuranceexternal icon, 2017. JAMA Network Open. 2020;3(5):e204514. doi:10.1001/jamanetworkopen.2020.4514