Acute migraine management in emergency departments is characterised by persistent polypharmacy, overuse of opioids and underuse of triptans, an Australian study has shown

In a review of treatment for 744 patients with a migraine diagnosis treated at St Vincent’s Hospital, Melbourne, between 2012 and 2016 neurologists found that nearly half of all presentations (46%) were managed with opioids such as oxycodone and Panadeine Forte. In contrast, only a minority of patients received triptans (7%).

The patients with migraine were predominantly young females, and two thirds presented after failed self medication with analgesic at home, most often with opioids (25%) .

The review, led by Dr Lakshini Gunasekera, found that a wide range of different drugs were used, many of them not guideline recommended.

Among the most common treatments prescribed for acute migraine were NSAIDS (37.4%), chlorpromazine (43.7%). Paracetamol was more frequently prescribed than aspirin (52% vs 18%). However antiemetics such as metoclopramide (31%),  ondansetron (12.1% and prochlorperazine (10%) were underused, the study authors said.

A quarter of patients (25%) received no guideline recommended medications.

“It is unclear to what extent contraindications, allergies, lack of knowledge about appropriate abortive therapies or physician preferences contributed to these observed practices,” they wrote.

“This is concerning as under-treatment of acute migraine can lead to migraine chronification and repeat ED presentations; further targeted interventions to address migraine management is required.”

They noted that about half of patients who had tried triptans at home were given opioids when they presented to the ED with migraine. This might reflect ED doctors’ familiarity with opioids and represented inappropriate use of opioids when initial therapy had failed, the authors said.

“Nurse-initiated paracetamol exists in this institution and its initial failure may be a reason for high opioid prescription, whereby doctors in ED ‘treat on the run’ without a patient review in order to alleviate patient pain,” they remarked.

They concluded that further work is needed to explore why opioids are overused for migraine treatment in Eds despite being discouraged in Therapeutic Guidelines and NHMRC guidelines.

“Our study has revealed the persistent mismanagement of acute migraine despite copious evidence regarding evidence-based management in the acute setting,” they wrote.

The findings are published in Emergency Medicine Australasia.