Narcotics (opioids) are still overused in ERs for migraines
Triptans, such as Imitrex or sumatriptan and similar drugs are “designer” drugs which were developed to specifically treat migraine headaches. They are highly effective and, after more than 20 years on the market, proven safe. Four out of the seven drugs in this category (Imitrex, Maxalt, Zomig, Amerge) are available in a generic form, which significantly lowers their cost, which was one of the obstacles for their widespread use. So, it would appear that now there is no reason for doctors not to prescribe triptans to migraine sufferers.
In 1998, emergency department doctors gave more than half of the patients suffering from migraine headaches opioids (narcotics) to relieve pain and, according to a new study, 12 years later, this hasn’t changed.
Despite the fact that triptans are widely considered to be the best drugs for acute migraine, the use of these drugs in the emergency department has remained at 10%, according to a study led by Benjamin Friedman, an emergency medicine doctor at the Montefiore Medical Center in the Bronx.
In 1998, about 51% of patients presenting with migraine at the emergency department were treated with an injection of a narcotic and in 2010, narcotics were given to 53% of the patients.
Other than narcotics (opioids) emergency department doctors often give injections of an NSAID (non-steroidal anti-inflammatory drug) Toradol (ketorolac) or a nausea drug, such as Reglan (metoclopramide). These two drugs are more effective (especially if given together) and have fewer potential side effects than narcotics. They also do not cause addiction and rebound (medication overuse) headaches, which narcotics do.
Dr. Friedman and his colleagues looked at the national data for 2010 and found that there were 1.2 million visits to the emergency departments for the treatment of migraine. Migraine was the 5th most common reason people come to the emergency room.
They also discovered that people who were given a triptan in the emergency department had an average length of stay in the ER of 90 minutes, while those given Dilaudid (hydromorphone) – the most popular narcotic, stayed in the ER for an average of 178 minutes.
Opioids should be used only occasionally – when triptans, ketorolac, and metoclopramide are ineffective or are contraindicated. This should be the case in maybe 5% of these patients, according to Dr. Friedman
One possible reason why ER doctors do not follow recommended treatments and use narcotics instead, is that they do not recognize a severe headache as migraine and misdiagnose it as sinus, tension-type or just as a “severe headache”. Many doctors still believe that migraine has to be a one-sided headache, or a visual aura must precede a migraine, or that the pain has to be throbbing. It is well established that none of these features are required for the diagnosis of migraine.
Another possible reason for the widespread use of opioid drugs in the ER is that doctors are very accustomed to using them, while triptans may be unfamiliar and require thinking about potential contraindications, what dose to give, what side effects to expect, etc.
In summary, if you or someone you know has to go to an ER with a severe migraine, ask for injectable sumatriptan (which you should have at home to avoid such visits to the ER) or ketorolac.
I agree, triptans preferably should be taken at the onset, although sumatriptan injection can help even at the peak of a migraine attack. Ideally, patients should be taking triptans, including the injection, at home.
Dr. Mauskop, thank you for all of your work and for this site! I am a chronic migraine sufferer and I did want to point out something that I’ve learned (and I know that I could teach doctors at this point) in regards to your mention of triptans being effective as abortive therapy in an ER situation; this actually is not the case and not a good idea, as even stated repeatedly by manufacturers that triptans need to be taken at the very ‘onset’ of a migraine. Basically, if they are taken after the onset of a migraine they become less and less effective, so by the time someone presents in an ER with a full blown migraine, the chances that a triptan will abort that migraine is slim to not at all. More than likely it will make it worse partly because when a triptan is taken it puts that patient in a drug box because you can’t mix triptans with certain other abortive types of medications. The other thing is that we seem to be entering what I see as a global era of ‘chronic’ migraine/cluster headaches, so the number of people who experience daily headaches, that have a tendency to catapult to full blown migraines on more than 15 days a month, is growing. If one has a headache ‘every day’, that becomes very confusing as to when the ‘onset’ of a migraine is, because any headache can be the signal that a migraine is coming, and since triptans are thought to cause rebounds, patients are only given so many a month, so that practice in and of itself becomes a very stressful, daily game of roulette as to when to take a triptan medication. I have met many people who triptans do not work for, not even when taken at the onset of a migraine. If they did we wouldn’t have this problem today. For me, they made my migraines so much worse that an ER or urgent care trip regularly followed taking them until that taught me that triptans for me are not a good idea. Just a side note, I do want to point out also that the MOH theory has actually been debunked by many like Harvard and Mayo at this point, yet it seems to take a while for actual prescribers to catch up to that reading. Many medications are put in this MOH box and it is simply an outdated theory that’s probably causing more stress to migraine suffers than good. Thanks again for all of your work and I hope that my comment is helpful!