Management of migraine in the emergency department: Findings from the 2010–2017 National Hospital Ambulatory Medical Care Surveys Philip R. Wang a, ⁎, Rocio Lopez b,c , Spencer S. Seballos a , Matthew J. Campbell d , Belinda L. Udeh b,c,e , Michael P. Phelan f a Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH, United States of America b Center for Populations Health Research, Cleveland Clinic, Cleveland, OH, United States of America c Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH, United States of America d Department of Pharmacy, Cleveland Clinic, Cleveland, OH, United States of America e Neurological Institute Center for Outcomes Research, Cleveland Clinic, Cleveland, OH, United States of America f Emergency Services Institute, Cleveland Clinic, Cleveland, OH, United States of America abstract article info Article history: Received 1 December 2020 Accepted 18 December 2020 Available online xxxx Keywords: Migraine Emergency department Headache Opioid NSAID Anti-emetics Objective: The study objective was to describe trends in the medical management of migraine in the emergency department (ED) using the 2010—2017 National Hospital Ambulatory Medical Care Survey (NHAMCS) datasets. Methods: Using the 2010–2017 NHAMCS datasets, we analyzed visits with a discharge diagnosis of migraine. Drug prescription frequencies between years were compared with the Rao-Scott chi-squared test. Adjusted odds ratios of opioid administration from 2010 to 2017 were calculated using weighted multivariable logistic re- gression with sex, age, race/ethnicity, pain-score, primary expected source of payment, and year as predictor var- iables. Results: Our analysis captured 1846 ED visits with a diagnosis of migraine from 2010 to 2017, representing a weighted average of 1.2 million US ED visits per year. Parenteral opioids were prescribed in 49% (95% CI: 40, 58) of visits in 2010 and 28%(95% CI: 15, 45) of visits in 2017 (p = 0.03). From 2010 to 2017, there was a 10% yearly decrease in opioid prescriptions. Metoclopramide and ketorolac were prescribed more frequently in years 2015 through 2017 than in 2010. Increased opioid administration was associated with female sex, older age, white race, higher pain score, and having Medicare or private insurance as the primary expected source of payment for all years. Conclusion: Opioid administration for migraine in EDs across the US declined 10% annually between 2010 and 2017, demonstrating improved adherence to migraine guidelines recommending against opioids. We identified several factors associated with opioid administration for migraine, identifying groups at higher risk for unneces- sary opioids in the ED setting. © 2020 Published by Elsevier Inc. 1. Introduction 1.1. Migraine in the emergency department Headache disorders are relatively common, with a prevalence of 47% worldwide [1]. Headache or pain in the head is the fourth most common chief complaint in emergency departments (EDs) nationwide and ac- counts for 3.1% of all visits [2]. To manage headaches properly, ED phy- sicians must differentiate between more common benign primary headache disorders and rarer life-threatening secondary causes of headache, including infection and trauma [3]. One of the more common primary headache disorders is migraine, which affects 15% of Americans, leads to 1.2 million ED visits annually, and has an estimated indirect impact of $17.2 billion a year on the US economy [3-5]. 1.2. Medical management of migraine in the ED Current guidelines for the management of migraine in the ED recom- mend a wide variety of pharmacotherapies. First-line agents include do- pamine antagonist anti-emetics, non-steroidal anti-inflammatory drugs (NSAIDs), and triptans [3,6-8]. Most guidelines do not recommend opi- oids because they are associated with longer ED stays, increased ED re- cidivism, and decreased sensitivity to more effective migraine treatments [9,10]. However, an analysis of the 2010 National Hospital Ambulatory Medical Care Survey (NHAMCS) demonstrated that 49% American Journal of Emergency Medicine 41 (2021) 40–45 ⁎ Corresponding author at: Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, EC-10 Cleveland Clinic, 9501 Euclid Ave, Cleveland, OH 44195, United States of America. E-mail address: wangp@ccf.org (P.R. Wang). https://doi.org/10.1016/j.ajem.2020.12.056 0735-6757/© 2020 Published by Elsevier Inc. Contents lists available at ScienceDirect American Journal of Emergency Medicine journal homepage: www.elsevier.com/locate/ajem