Acute Migraine

migraine headache
Migraines Are a Very Common Condition and Can Be Severely Debilitating

Migraines can be severely debilitating and are considered one of the main causes of disability worldwide.[1] 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.[2]

Acute Migraines are Often Treated in the Emergency Department Setting

In the Emergency Department (ED) setting, headaches overall account for about 3% of all ED visits annually in the United States.[3] 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 nonopioid treatments for acute migraines, opioids are commonly prescribed for acute migraines in the ED.[5] For example, opioids were ordered for 35.8% of ED visits for acute migraines during a fourteen-month period, which included 1,222 total visits. 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.[6]

Prescription Frequency

36 percent

36% of adolescents and young adults who visited an Emergency Department with a migraine received an opioid prescription.

Too Many Pills, Too Many Times

7 days and dosage of 22.5 MME

Opioids are prescribed for acute migraines at a median total of 22.5 MME and an average of 7 days supply.

Treating Acute Pain Safely and Effectively
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Summary of Treatment Recommendations

The American Headache Society
  • Acute Treatment of Migraine in Adults: The American Headache Society Evidence Assessment of Migraine Pharmacotherapiesexternal icon (2015)
  • “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.”
  • Management of Adults With Acute Migraine in the Emergency Department: The American Headache Society Evidence Assessment of Parenteral Pharmacotherapies (2016)external icon
  • “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] 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

[2] 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.

[3] 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.

[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] 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.

[6] 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 Insurance, 2017. JAMA Network Open. 2020;3(5):e204514. doi:10.1001/jamanetworkopen.2020.4514