Opioids as the earliest acute treatment for emergency department headache and short‐term all‐cause emergency department return: A two‐center comparative cohort study

Objective

To compare first‐line emergency department (ED) treatment classes for acute headache on short‐term all‐cause ED return.

Background

In‐ED pain relief anchors acute headache trials but is recorded incompletely in routine care. All‐cause ED return has not been used to compare first‐line treatments; guidelines favor dopamine‐receptor antagonists over opioids for acute migraine.

Methods

Retrospective two‐center cohort of adults treated for headache in the ED (MIMIC‐IV‐ED, 2011–2019; MC‐MED, 2020–2022); first‐line treatment was the earliest qualifying acute agent. The primary contrast was opioids versus guideline‐preferred dopamine‐receptor antagonists. The primary outcome was 72‐h all‐cause ED return among discharged patients; 7‐day return was secondary. Estimates, adjusted for prespecified confounders available in both databases, are reported as risk ratios (RRs) with 95% confidence intervals (CIs), pooled and site‐specific.

Results

Among 13,285 treated adults (10,799 MIMIC‐IV‐ED; 2486 MC‐MED), MIMIC‐IV‐ED opioid recipients were older than dopamine‐antagonist recipients (median 48 vs. 39 years) and more often high‐acuity at triage (980/1895 [51.7%] vs. 900/3056 [29.5%]). First‐line opioids were associated with higher 72‐h all‐cause ED return (adjusted risks 6.8% vs. 3.8%; RR 1.78; 95% CI 1.31–2.32) and 7‐day return (10.7% vs. 6.6%; RR 1.62; 95% CI 1.28–1.99). The MC‐MED estimate was directionally concordant but anchors direction only (85 opioid‐treated discharged patients). Restricting to a headache‐coded or headache‐triaged return attenuated the association, which was no longer statistically significant (72‐h RR 1.31; 95% CI 0.91–1.88).

Conclusion

Patients selected for first‐line opioids were older and higher acuity and returned more often within 72 h and 7 days at both health systems. These risk‐adjusted associations, conditional on discharge, reflect all‐cause ED utilization rather than confirmed headache recurrence and do not establish that changing first‐line class would change return rates. The attenuated headache‐specific result is as consistent with administrative undercoding as with no association and is not a justification for prescribing opioids.

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