Evaluation of the assessment and management of acute migraines in two Australian metropolitan emergency departments

Abstract

Introduction: Migraines are one of the commonest presenting complaints to emergency departments (ED), and may result in prolonged length of stay with symptoms being severe and refractory to typical remedies, such as paracetamol, non-steroidal anti-inflammatory drugs and triptans. The objective of this study was to describe and compare patient demographics, presentation, management and outcomes to hospital discharge between first presenters and patients with a history of migraines in two metropolitan emergency departments in Melbourne, Australia. Given that the assessment and management of patients who have had a prior history of migraines is likely to be substantially different, patients were subgrouped by this exposure variable. Methods: A total of 365 patients were identified retrospectively during the study period of March 2013 – September 2014 that met the inclusion criteria of a headache with no organic cause and/or symptoms consistent with visual or abdominal migraines. Presenting pain scores, assessment, management and disposition were extracted using explicit chart review. Results: The mean age of patients included was 37.8 years and 23.3% were males. Significantly more first presenters were investigated with a CT scan of the brain (34.4% as compared to 22.9% of patients with a prior history of migraine). Initial management included administration of paracetamol in 178 (48.8%) cases, NSAIDs (mostly ibuprofen and aspirin) in 187 (51.2%) and parenteral dopamine antagonists (e.g. metoclopramide, prochlorperazine and chlorpromazine) in 191 (52.3%) cases. Migraine-specific agents such as triptans were prescribed in 46 (12.6%) and ergots in two (0.5%) cases. Opioids such as morphine or oxycodone were administered in 94 (25.8%) cases. There was no statistical difference in the management of patients with a history of migraines as compared to first presenters, with the exception of the use of intravenous fluids and parenteral dopamine antagonists. The median length of stay in the ED was 4 (inter-quartile range 2–7) hours, with 163 (44.7%) patients admitted to the short-stay unit. A pain score of ≥ 5 was recorded at discharge in 31 (8.5%) patients. Disposition was similar across both groups of patients. Conclusions: Although first presenters seem to be more thoroughly investigated, the acute management of migraine did not differ largely between patients who had a history of migraine compared with first presenters. The management of acute migraine in the ED setting has varied efficacy, suggesting that further research into newer therapeutic options is needed.