Emergency department treatment of acute migraine and risks of hospital admission and 30-day revisits: a retrospective cohort study

Abstract

Migraine is a common reason for emergency department (ED) visits, but little is known about how the choice of acute treatment relates to hospital admission and early return visits. We characterized ED treatment patterns for acute migraine and identified predictors of hospital admission and 30-day ED revisits. We performed a retrospective cohort study of all ED visits with a primary diagnosis of migraine (ICD-9 346.x or ICD-10 G43.x) in MIMIC-IV-ED (2011–2019). Multivariable logistic regression restricted to seven prespecified covariates identified predictors of admission, and Cox regression predictors of 30-day ED revisit; prespecified sensitivity analyses checked robustness. Among 1,326 visits (86.0% female; median age 34 years), 55 (4.1%) ended in admission and 15.6% were followed by a 30-day ED revisit (27.5% among visits with observable follow-up; 4.2% within 72 h). Dopamine antagonists were given in 65.6% of visits and opioids in 22.5%. Dopamine antagonist administration was associated with lower admission odds (adjusted OR 0.28, 95% CI 0.14–0.53; P  < 0.001), robust to sensitivity analyses including a broader six-agent definition (OR 0.31). Opioid administration was associated with higher admission odds (OR 2.40, 95% CI 1.32–4.35) and with about twice the hazard of a 30-day revisit (HR 1.96, 95% CI 1.20–3.22; P  = 0.007); the revisit association was identical by construction in the complete-case analysis but weakened among patients with no prior ED visits, so it may be partly explained by pre-existing ED utilization rather than by the index treatment. Status migrainosus identified from ED discharge diagnoses (23 visits, 1.7%) showed a numerically higher admission rate (13.0% vs. 4.0%) that was not significant after adjustment (OR 2.18, 95% CI 0.57–8.33); the stronger association under a combined ED-plus-inpatient definition (OR 14.72) was attributable to ascertainment from inpatient codes available only to admitted patients. Mood or anxiety disorder was associated with a 30-day revisit (HR 2.04, 95% CI 1.45–2.88) but not with admission (OR 1.55, 95% CI 0.80–2.97). In this observational cohort, dopamine antagonist therapy was associated with lower odds of hospitalization and opioid use with earlier return visits. These hypothesis-generating associations identify candidate targets for emergency migraine care.