Changing Treatments in Emergency

Treating migraine in the emergency room of a hospital is a challenge, and opinions and methods are changing rapidly. Narcotics were once common, but researchers began to discover that patients taking narcotics in emergency (instead of other treatments – more on that in a moment) actually tended to be in the hospital longer and come back more often. This isn’t to suggest that they were “drug seekers”, but simply that the narcotics were less effective than was once believed – and side effects were more common.

As our knowledge of migraine treatment has expanded, many other treatments have become commonly available. More and more, treatments are being given such as – hydration with magnesium (intravenous), sumatriptan, NSAIDS (such as ketorolac or diclofenac), and dopamine antagonists such as metoclopramide (for nausea and other gastric problems).

And older medication, dihydroergotamine, has been persistently used as well.

A meta study published this month in the American Journal of Emergency Medicine highlighted some of these changed (see link at bottom of this article). Comparing how things were at the turn of the millennium, the study found:

• Dopamine antagonists are now used 3-4 times more often
• intravenous fluids used over 6x more often
• Dexamethasone (a corticosteroid) used 22% more (this one is quite new – and it seems to help keep migraine from returning in the short term)
• Ketorolac used 7-8x more often (also somewhat new in emergency)

Narcotics are only give 1/3 as often as they were. Not only that, “discharge prescriptions” are down to a third or less or what they were.

An obvious question is – are the new procedures helping? That may be a complex question, but the same study did find that return-to-emergency rates were also down, to a third of what they were back in 1999-2000.

That return rate may not be quite as great as it sounds – only 12% returned before, now only 4%. Still, a significant difference.

For more on emergency room procedures, see:

• What You Need to Know about Migraine in Emergency
• Sequence of Treatments in Emergency – what works?
• IV Fluid Use Up, Narcotics Use Down in Patients With Migraine Admitted to ED