ED Treatment of Migraine Headache: Factors Influencing Pharmacotherapeutic Choices

Study Objective.—To evaluate the factors that influence clinicians' choices of parenteral medications in the emergency department (ED) management of migraine headache. Background.—Migraine headache is a common problem in the United States. Many migraineurs require periodic ED management. Though a large variety of parenteral medications are used by ED clinicians in the treatment of migraine, little research has been directed to the reasons why providers use the medications they do. Methods.—This study used a self-administered questionnaire for providers from 3 geographically distinct EDs to evaluate their pharmacotherapeutic preferences in the treatment of uncomplicated migraine based on a fictitious scenario. Factors influencing medication choices were rated on a 5-point Likert scale and analyzed descriptively. Hypothetical practice patterns from the questionnaires were compared with actual practice patterns from a prior study from the same institutions. Results.—Eighty-three percent of surveys were returned, the majority from attending physicians (71%), as their initial drugs-of-choice providers preferred dopaminergic antiemetics (93%) and parenteral NSAIDs (22%). If initial therapy failed, opioids (40%) with nonspecific antiemetics (24%) were preferred as second-line agents. Choice of therapy was influenced (in descending order) by medication availability and its antimigraine properties, the providers' training, current departmental practice patterns, and national practice guideline recommendations. Opioid use was influenced by patients' failure to respond to ED and outpatient alternatives and the presence of contraindications/intolerances to non-opioids. When these results were compared to a prior study of actual practice patterns, a range of discordance was observed, which varied significantly by institution. Conclusion.—Emergency clinicians report that a variety of factors influence their parenteral pharmacotherapy in the management of patients with migraine headache. The comparison of hypothetical practice patterns with actual practice patterns reveals a range of institution-specific discordance. There is discordance between providers' responses to a fictitious scenario and their previously recorded practice patterns with regional variation.