Rates and Predictors of Using Opioids in the Emergency Department to Treat Migraine in Adolescents and Young Adults

A qualitative evidence synthesis of patient perspectives on migraine treatment features and outcomes

OBJECTIVES

We aimed to identify migraine treatment features preferred by patients and treatment outcomes most valued by patients.

BACKGROUND

The values and preferences of people living with migraine are critical for both the choice of acute therapy and management approach of migraine.

METHODS

We conducted a qualitative evidence synthesis. Two reviewers independently selected studies, appraised methodological quality, and undertook a framework synthesis. We developed summary of findings tables following the approach of Grading of Recommendations, Assessment, Development and Evaluations Confidence in the Evidence from Reviews of Qualitative Research to assess confidence in the findings.

RESULTS

Of 1691 candidate references, we included 19 studies (21 publications) involving 459 patients. The studies mostly recruited White women from North America (11 studies) and Europe (8 studies). We identified eight themes encompassing features preferred by patients in a migraine treatment process. Themes described a treatment process that included shared decision-making, a tailored approach, trust in health-care professionals, sharing of knowledge and diversity of treatment options, a holistic approach that does not just address the headache, ease of communication especially for complex treatments, a non-undermining approach, and reciprocity with mutual respect between patient and provider. In terms of the treatment itself, seven themes emerged including patients' preferences for nonpharmacologic treatment, high effectiveness, rapidity of action, long-lasting effect, lower cost and more accessibility, self-management/self-delivery option that increases autonomy, and a mixed preference for abortive versus prophylactic treatments. The treatment outcomes that have high value to patients included maintaining or improving function; avoiding side effects, potential for addiction to medications, and pain reoccurrence; and avoiding non-headache symptoms such as nausea, vomiting, and sensitivity to light or sounds.

CONCLUSION

Patient values and preferences were individually constructed, varied widely, and could be at odds with conventional medical perspectives and evidence of treatment effects. Considering the availability of numerous treatments for acute migraine, it is necessary that decision-making incorporates patient values and preferences identified in qualitative research. The findings of this qualitative synthesis can be used to facilitate an individually tailored approach, strengthen the patient-health-care system relationship, and guide choices and decisions in the context of a clinical encounter or a clinical practice guideline.

Standardized Health data and Research Exchange (SHaRE): promoting a learning health system

Aggregate de-identified data from electronic health records (EHRs) provide a valuable resource for research. The Standardized Health data and Research Exchange (SHaRE) is a diverse group of US healthcare organizations contributing to the Cerner Health Facts (HF) and Cerner Real-World Data (CRWD) initiatives. The 51 facilities at the 7 founding organizations have provided data about more than 4.8 million patients with 63 million encounters to HF and 7.4 million patients and 119 million encounters to CRWD. SHaRE organizations unmask their organization IDs and provide 3-digit zip code (zip3) data to support epidemiology and disparity research. SHaRE enables communication between members, facilitating data validation and collaboration as we demonstrate by comparing imputed EHR module usage to actual usage. Unlike other data sharing initiatives, no additional technology installation is required. SHaRE establishes a foundation for members to engage in discussions that bridge data science research and patient care, promoting the learning health system.

Acute Treatments for Episodic Migraine in Adults: A Systematic Review and Meta-analysis

IMPORTANCE

Migraine is common and can be associated with significant morbidity, and several treatment options exist for acute therapy.

OBJECTIVE

To evaluate the benefits and harms associated with acute treatments for episodic migraine in adults.

DATA SOURCES

Multiple databases from database inception to February 24, 2021.

STUDY SELECTION

Randomized clinical trials and systematic reviews that assessed effectiveness or harms of acute therapy for migraine attacks.

DATA EXTRACTION AND SYNTHESIS

Independent reviewers selected studies and extracted data. Meta-analysis was performed with the DerSimonian-Laird random-effects model with Hartung-Knapp-Sidik-Jonkman variance correction or by using a fixed-effect model based on the Mantel-Haenszel method if the number of studies was small.

MAIN OUTCOMES AND MEASURES

The main outcomes included pain freedom, pain relief, sustained pain freedom, sustained pain relief, and adverse events. The strength of evidence (SOE) was graded with the Agency for Healthcare Research and Quality Methods Guide for Effectiveness and Comparative Effectiveness Reviews.

FINDINGS

Evidence on triptans and nonsteroidal anti-inflammatory drugs was summarized from 15 systematic reviews. For other interventions, 115 randomized clinical trials with 28 803 patients were included. Compared with placebo, triptans and nonsteroidal anti-inflammatory drugs used individually were significantly associated with reduced pain at 2 hours and 1 day (moderate to high SOE) and increased risk of mild and transient adverse events. Compared with placebo, calcitonin gene-related peptide receptor antagonists (low to high SOE), lasmiditan (5-HT1F receptor agonist; high SOE), dihydroergotamine (moderate to high SOE), ergotamine plus caffeine (moderate SOE), acetaminophen (moderate SOE), antiemetics (low SOE), butorphanol (low SOE), and tramadol in combination with acetaminophen (low SOE) were significantly associated with pain reduction and increase in mild adverse events. The findings for opioids were based on low or insufficient SOE. Several nonpharmacologic treatments were significantly associated with improved pain, including remote electrical neuromodulation (moderate SOE), transcranial magnetic stimulation (low SOE), external trigeminal nerve stimulation (low SOE), and noninvasive vagus nerve stimulation (moderate SOE). No significant difference in adverse events was found between nonpharmacologic treatments and sham.

CONCLUSIONS AND RELEVANCE

There are several acute treatments for migraine, with varying strength of supporting evidence. Use of triptans, nonsteroidal anti-inflammatory drugs, acetaminophen, dihydroergotamine, calcitonin gene-related peptide antagonists, lasmiditan, and some nonpharmacologic treatments was associated with improved pain and function. The evidence for many other interventions, including opioids, was limited.

Burden of increasing opioid use in the treatment of migraine: Results from the Migraine in America Symptoms and Treatment Study

OBJECTIVE

We sought to assess factors associated with the frequency of self-reported prescription opioid use in persons with migraine, including demographic variables, comorbidities, headache characteristics, and patterns of consultation.

BACKGROUND

Despite the dose-dependent effect of opioids on migraine progression and the association with negative outcomes, migraine treatment often includes opioids. The Migraine in America Symptoms and Treatment Study focuses on individuals with migraine who receive prescription acute medications, including those receiving and those not receiving opioids.

METHODS

This web-based panel survey identified people in the United States with migraine using a validated screener. This analysis stratified people with migraine into 4 groups based on days of monthly opioid use: non-opioid users, ≤3 days, 4-9 days, and ≥10 days per month.

RESULTS

Of 15,133 respondents with migraine, 4701 (31%) reported acute prescription medication use for headache/migraine in the previous 3 months (mean age 45 years, 71.6% [3367/4701] female), of whom 32.5% (1528/4701) reported opioid use. About one-third of respondents with primary care or neurology consults in the prior 6 months reported receiving an opioid, and more than half of respondents (209/391, 53.5%) with a pain clinic consultation did so. Models compared those using opioids ≤3 days/month (879/4701, 18.7%), 4-9 days/month (304/4701, 6.5%), ≥10 days/month (345/4701, 7.3%) to non-opioid users (3173/4701, 67.5%). Compared to non-opioid users, infrequent users (≤3 days/month) were more likely to be male and less likely to have chronic migraine or to screen positive for anxiety and depression; and frequent opioid users (the 4-9 days/month and the ≥10 days/month groups) were more likely to be male, to smoke, to be obese, to report greater pain interference, to have moderate to severe disability, to have symptoms of anxiety and depression, to use fewer triptans and nonsteroidal anti-inflammatory drugs, and to have poor acute treatment optimization.

CONCLUSION

Among prescription medication users, this cross-sectional analysis shows that increasing use of prescription opioids is associated with male gender, chronic migraine, more severe disability, anxiety and depression, poor acute treatment optimization, and treatment in a pain clinic.

Opioid Use to Treat Migraine Headaches in Hospitalized Children and Adolescents

OBJECTIVES

Prescription of opioids to treat pediatric migraine is explicitly discouraged by treatment guidelines but persists in some clinical settings. We sought to describe rates of opioid administration in pediatric migraine hospitalizations.

METHODS

Using data from the Pediatric Health Information System, we performed a cross-sectional study to investigate the prevalence and predictors of opioid administration for children aged 7 to 21 years who were hospitalized for migraine between January 1, 2016, and December 31, 2018.

RESULTS

There were 6632 pediatric migraine hospitalizations at 50 hospitals during the study period, of which 448 (7%) had an opioid administered during the hospitalization. There were higher adjusted odds of opioid administration in hospitalizations for non-Hispanic black (adjusted odds ratio [aOR], 1.68; P < .001) and Hispanic (aOR, 1.54; P = .005) (reference white) race and ethnicity, among older age groups (18-21 years: aOR, 2.74; P < .001; reference, 7-10 years), and among patients with higher illness severity (aOR, 2.58; P < .001). Hospitalizations during which an opioid was administered had a longer length of stay (adjusted rate ratio, 1.48; P < .001) and higher 30-day readmission rate (aOR, 1.96; P < .001). By pediatric hospital, opioid administration ranged from 0% to 23.5% of migraine hospitalizations. Hospitals with higher opioid administration rates demonstrated higher adjusted readmission rates (P < .001) and higher adjusted rates of return emergency department visits (P = .026).

CONCLUSIONS

Opioids continue to be used during pediatric migraine hospitalizations and are associated with longer lengths of stay and readmissions. These findings reveal important opportunities to improve adherence to migraine treatment guidelines and minimize unnecessary opioid exposure, with the potential to improve hospital discharge outcomes.

Sex-Specific Pharmacotherapy for Migraine: A Narrative Review

Migraine is a common neurological disorder characterized by recurrent headache episodes that accompany sensory-motor disturbances, such as higher sensitivity to touch and light, extremity heaviness or weakness, and speech or language disabilities. Worldwide, migraine is one of the top 10 causes of disability and hence poses a huge economic burden to society. On average, migraine occurs in 12% of population but its occurrence is sexually dimorphic, as it is two to three times more prevalent in women than in men. This female to male ratio of migraine prevalence is age- and sex hormone-dependent. Advancements in understanding migraine pathogenesis have also revealed an association with both genetics and epigenetics. The severity of migraine, in terms of its attack duration, headache intensity, frequency, and occurrence of migraine-associated symptoms, has generally been reported to be greater in women. Sex differences in migraine disability and comorbidities, such as psychiatric disorders, have also been noted in some population-based studies. However, research on sex-related differences in response to migraine treatments is relatively scarce. Although a general observation is that women consume more medication than men for migraine treatment, strategies for the use of abortive and preventive medications for migraine are generally similar in both sexes. This narrative review summarizes available findings on sexually distinct responses to abortive and prophylactic pharmacotherapy of migraine. Basic experimental data and clinical findings will be presented, and potential mechanisms underlying sex-based responses will be discussed to highlight the importance and value of sex-based treatment in migraine research and practice.