30 Jun NYU Neurologist Comments On New Guidelines For Emergency Room Treatment of Migraines
MedicalResearch.com Interview with:
Mia Minen, MD, MPH
Assistant Professor of Neurology
NYU Langone Medical Center
MedicalResearch.com Editor’s note: The American Headache Society has issued new guidelines on “The Management of Adults With Acute Migraine in the Emergency Department” (1,2)
Dr. Minen, Director of Headache Services at NYU Langone Medical Center, discusses these new guidelines below.
MedicalResearch.com: What is the background for these new guidelines?
How common/severe is the issue of migraine or headache presentation to the ER?
Dr. Minen: These guidelines were needed because previous research shows that there are about 1.2. million visits to the emergency department (ED) each year for migraine, and over 25 different medications are sometimes used for treatment. Many of these medications don’t have evidence-based data to back their usage, and opioids are especially likely to be prescribed in between 60 and 70 percent of these cases, despite their lack of efficacy and risks. The American Headache Society convened an expert panel to review the existing evidence on all the medications used to treat migraines in the ED, and we developed these new treatment guidelines.
MedicalResearch.com: What options are available to treat migraine in an emergent setting? What other disease processes have to be excluded before treatment? Are there concerns about drug-seeking behaviours and how are these concerns best handled?
Dr. Minen: After a review of the literature, our guidelines state that the three medications with the highest recommendation (Level B recommendation) for the acute treatment of migraine in the ED were metroclopramide, prochlorperazine and subcutaneous sumatriptan. Emergency department physicians should generally feel comfortable providing these medications: the first two, metoclopramide and prochlorperazine, are also used for nausea. The sumatriptan recommendation is important because it is a medication that patients can be prescribed on discharge from the emergency department.
Another key point we found is that the steroid dexamethasone should be offered to patients to prevent recurrence of the migraine, because studies we reviewed indicate that people with migraines leave the ED still in pain. The guidelines state that dexamethasone should be offered to patients with migraines to prevent recurrence.
MedicalResearch.com: What should readers take away from your report:
Dr. Minen: These are the first guidelines for the treatment of migraine in the emergency department. In a previous study I co-authored with Drs. Benjamin Friedman and Elizabeth Loder, half of the patients did not treat their headache with medication before coming to the ED. Moreover, only 11% reported taking a triptan (like the sumatripan in our guidelines) on the day of presentation to the ED. Thus, if the medication works in the ED, patients can then try it at home the next time an attack occurs and this can hopefully prevent additional visits to the ED for migraine.
Additionally, the literature also shows that almost 60% of patients were not asked to follow-up with a physician after coming to the ED with a headache. It is important that there is communication between ED physicians and primary care physicians, particularly to see if the acute medications worked in the ED or if there are ongoing issues, and so that there can be an assessment of whether migraine preventive treatment is indicated. If the migraines are not responsive to the evidence-based ED migraine treatments we recommend, and if several preventive medications are tried but are ineffective, then referral to a neurologist or headache specialist might be needed.
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1: Headache doi: 10.1111/head.12835 VC 2016 American Headache Society
Management of Adults With Acute Migraine in the Emergency Department: The American Headache Society Evidence Assessment of Parenteral Pharmacotherapies Serena L. Orr, MD; Benjamin W. Friedman, MD, MS; Suzanne Christie, MD, FRCPC; Mia T. Minen, MD; Cynthia Bamford, MD; Nancy E. Kelley, MD, PhD; Deborah Tepper, MD
Accepted for publication April 13, 2016.
2: The Management of Adults With Acute Migraine in the Emergency Department
Headache doi: 10.1111/head.12865 VC 2016 American Headache Society Published by Wiley Periodicals, Inc
Stephen Silberstein, MD Jefferson Headache Center, Philadelphia, PA
Note: Content is Not intended as medical advice. Please consult your health care provider regarding your specific medical condition and questions.
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