• Our objective was to analyze opioid and non-opioid treatment of migraine at the Emergency Department (ED) of University of Washington and Harborview Medical Centers in Seattle, Washington.

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Published data from 1998 shows 51% of migraine patients treated in the ED in the USA received parenteral opioids. Much evidence since has shown the efficacy and safety of non-opioid treatments, while linking opioid use to ED recidivism, transformation to chronic headache, and opioid-related problems. Despite this, a follow up study showed the rate had actually increased to 59%.

• We analyzed data from 1,413 patients with diagnosis of migraine by ICD-9 or ICD-10 out of a total 144,094 patients seen in the ED at the University of Washington or Harborview Medical Center between 01/01/2014, when the medication database became searchable, and 02/01/2018. We recorded patient demographics and the opioid and non-opioid migraine treatments during this time frame.

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Among non-opioid treatments, ketorolac (36.9%), prochlorperazine (43.2%), ondansetron (24.9%) and metoclopramide (20.5%) were used frequently. Corticosteroids and triptans were used infrequently, 4.5% and 2.4% respectively. Opioids were used in 19% of the group, primarily hydromorphone (10.1%) and morphine (5.7%). There did not appear to be a significant change in opioid use over individual years between 2014-2018.

The use of opioids in our institutions was dramatically lower than the overall rate found in EDs across the US, 19% vs. 59%.  The use of algorithms to diagnose and treat headache in the ED was found, in a Cleveland Clinic study, to cut the rate of prescribing of barbituates and opioids from 66% to 6.8%, although this rate crept back up over time. IV hydromorphone is the most popular opioid for migraine nationwide in ED’s and further education is needed to discourage this use.