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From the Department of Psychiatry (I. Colman), Cambridge University, UK; and Division of Emergency Medicine (Drs. Rothney and Rowe, S.C. Wright, B. Zilkalns), University of Alberta, Edmonton, Canada.
Address correspondence and reprint requests to Dr. B.H. Rowe, Division of Emergency Medicine, University of Alberta, 1G1.43 Walter Mackenzie Health Sciences Center, 8440 112 St., Edmonton, Alberta, Canada T6G 2B7; e-mail: Brian.Rowe{at}ualberta.ca
Objective: Treatment of acute migraine headache with narcotics is potentially ineffective and may lead to abuse. The authors examined the treatment practice variation across five linked EDs in one Canadian center, focusing on the use of narcotic analgesics and factors associated with their use.
Methods: Five hundred acute migraine headache patient charts were randomly selected from five Canadian EDs. Charts underwent a structured review to determine medication use. Data were analyzed, comparing those who received narcotics as first-line treatment with those who did not, using 
2 and t-tests and logistic regression.
Results: The majority of patients (59.6%) received narcotics as first-line treatment. Numerous factors were associated with first-line narcotic treatment. Having taken antiheadache medications prior to ED presentation (odds ratio [OR]: 2.63; 95% CI: 1.53, 4.51) and hospital of presentation being other than Hospital A (e.g., Hospital D, OR: 6.32; 95% CI: 2.76, 14.46) increased the odds of receiving first-line narcotics. Having received a more urgent triage score (OR: 0.4; 95% CI: 0.24, 0.65) or having a longer duration of headache (OR: 0.994; 95% CI: 0.99, 0.99) decreased the odds of receiving first-line narcotics.
Conclusions: Acute migraine management in these EDs does not meet current consensus guidelines. Factors associated with narcotic use are predictable, and a concerted effort to replace narcotics with more evidence-based first-line treatments is needed.
Received December 9, 2003. Accepted in final form March 8, 2004.
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