To determine the practice preferences of providers for acute migraine treatment in the emergency room setting.

A retrospective chart review was conducted. Inclusion criteria are visits for patients aged 18 to 50 years old with a history of migraine (ICD 10 code G43), who presented to the ED at our institution for acute migraine attacks from June to September 2018. Exclusion criteria are comorbidities that would preclude various acute migraine treatments. Data was gathered on which medications with current American Headache Society (AHS) recommendations Level A to Level C evidence were administered.

99 ED visits met the selection criteria. Only 33% of the visits received at least one medication with AHS level A evidence for acute migraine treatment; of these, 81% received acetaminophen, 16% received ibuprofen, 3% received sumatriptan. Interestingly, 74% of the visits received ketorolac and 84% received metoclopramide – both have level B evidence. The most frequently used medication with level C evidence was dexamethasone, at 18%.

Available medications with level A evidence for acute migraine treatment is under-utilized in the ED even when there is no clear contraindication, and medications with level B evidence were used more frequently. A practice gap is therefore identified. Nonetheless, current literature suggests that selecting the best individualized treatment does not exactly equate to simply selecting a medication with the highest level of evidence. Further studies need to examine how differential rates in using medications from different level of evidence can impact other parameters such as patient satisfaction and ED patient flow.