Barrow Neurological Institute, University of Calgary study urges “major change” to migraine treatment in Emergency Departments

Advises that injectable treatments must be offered, reducing reliance on opioids

A new study by Phoenix’s Barrow Neurological Institute and the University of Calgary has found which injectable treatments showed the most benefit for migraine patients and should be routinely offered by Emergency Departments (ED) when feasible. The findings from the study will update the guidelines for the American Headache Society.

Based on a systematic review of clinical trial data, the study presents new recommendations for ED treatment guidelines for migraine attacks, replacing recommendations that were last updated in 2016. Researchers say the new guidelines will reduce reliance on opioids and make migraine treatment in the ED more consistent and evidence-based.

“This update marks a major change in Emergency Department migraine care by introducing greater occipital nerve blocks and elevating intravenous prochlorperazine to level A (must offer) recommendations based on new high-quality evidence,” said the study’s co-author, Jennifer Robblee, MD, a neurologist and headache specialist at Barrow Neurological Institute, which is part of Dignity Health St. Joseph’s Hospital and Medical Center in Phoenix.

“The evidence is strong that occipital nerve blocks are an effective and safe treatment to address pain from migraine attacks and must be offered to patients in Emergency Departments,” adds study co-author Dr. Serena Orr, MD, neurologist, and associate professor at the University of Calgary’s Cumming School of Medicine.

The study, which also included researchers in New York and Ottawa was published this week in Headache: The Journal of Head and Face Pain.

Migraine is a leading cause of headache among ED patients, accounting for approximately one-fourth of the 3.5 million annual headache-related visits in the U.S. But researchers say clinical outcomes for migraine treatment in the ED are inadequate, with only 37.3 percent of patients reporting no headache at discharge.

Researchers note that despite existing guidelines from the American Headache Society, management of migraine cases varies widely across ED settings nationwide. Their goal was to provide higher quality evidence to guide management and improve patient outcomes.

The authors note that opioid use remains common in headache-related ED care.

Researchers aimed to answer the following questions with high-quality evidence:

• Which injectable medications should be considered effective for adults with migraine who visit an ED?
• Are nerve blocks, including sphenopalatine ganglion blocks, effective for the treatment of adults with migraine who visit an ED?

To find answers, researchers examined 26 new trials that have occurred since the 2016 American Headache Society guideline publication, including treatments like nerve blocks and eptinezumab, which may lead to improvement in symptoms and pain freedom at discharge.

“Because nerve block use requires trained personnel and supplies, dissemination of procedural training and support for implementation will be essential,” Dr. Orr said.

The authors note that the biggest challenge will be disseminating and implementing the new recommendations for some Emergency Departments, including modifying order sets and changing physician behavior to adopt the new therapies.