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Perioperative scripts for migraine abortive drugs linked with fewer pain readmissions



Patients with a history of migraine who underwent any type of surgery and then received a perioperative prescription for a headache abortive agent such as a triptan had 37% fewer readmissions for pain during the 30 days following surgery compared with patients who did not receive a migraine abortive prescription, according to an observational review of nearly 22,000 migraine patients from the Boston area.

Mitchel L. Zoler/MDedge News

Dr. Katharina Platzbecker

While this statistically significant observational association must be viewed with caution, it provides compelling evidence for clinicians to prescribe a migraine abortive agent to migraineurs soon after surgery so that patients have these drugs handy if a migraine strikes, a possibility made likely by the stress and disruption of surgery, Katharina Platzbecker, MD, said at the annual meeting of the American Headache Society.

Postoperative migraine patients who received an abortive prescription specifically for a triptan or ergotamine showed an even stronger protective association, with an adjusted, statistically-significant 67% reduced rate of 30-day readmission for pain compared with the 50% of migraine patients who did not receive an abortive agent prescription after their surgery, said Dr. Platzbecker, a research fellow in the department of anesthesia, critical care, and pain medicine at Beth Israel Deaconess Medical Center in Boston. Only 8% of patients in the study received a triptan or ergotamine, with the vast majority of these patients getting a triptan.

The other types of abortive drugs prescribed perioperatively to migraine patients were NSAIDs or acetaminophen, received by 47% of the patients studied. The adjusted analysis showed that patients who received a prescription for one of these drugs had a statistically significant 35% reduced rate of 30-day readmission for pain. Patients who did not receive a prescription for a migraine abortive drug often got an opioid prescription, which went to 87% of the entire study population. Some patients received perioperative prescriptions for more than one drug. The analysis also showed that periopertive opioid prescriptions had no significant association with the 30-day rate of pain readmissions. In addition, prescription of any pain-reducing medication immediately prior to surgery as prophylaxis, which occurred in 17% of patients, had no significant association with the rate of 30-day postoperative pain readmission.

Despite the lack of clear causal evidence, clinicians should “definitely” be more aggressive in prescribing abortive treatments, especially triptans, to patients with a history of migraine who undergo surgery, Dr. Platzbecker said in an interview. These patients “are likely at risk for migraine [episodes] after surgery,”

Her study used data collected from nearly 25,000 patients with a history of a migraine billing diagnosis who underwent surgery and was a patient in either the Beth Israel or Partners (Massachusetts General Hospital and Brigham and Women’s Hospital) health systems during 2005-2017. Complete data that fulfilled the requirements of the study were available for 21,932 of these patients, of whom 11,011 (50%) received a perioperative prescription for an abortive drug and 10,921 (50%) did not. The prescribing occurred totally at the discretion of each patient’s physicians and surgeons. The researchers defined perioperative prescription as a billing entry for a drug anytime after surgery and within 30 days of hospital discharge or until readmission. The entire group studied averaged about 50 years old, more than 80% were women, and those who received an abortive treatment prescription generally had longer surgeries, more inpatient surgeries, and higher rates of various comorbidities. The adjusted statistical analysis took into account baseline differences like these.

Additional sensitivity analyses showed that perioperative prescriptions for abortive treatments also linked with significant reductions in all 30-day hospital readmissions, and with 30-day pain readmissions in patients who received surgery as inpatients as well as in those who were outpatients, and the association was specific to migraine patients. When Dr. Platzbecker expanded the group of patients she examined to more than 62,000 with any headache diagnosis the association between receiving a prescription for an abortive treatment and reduced 30-day pain readmissions became statistically insignificant.

Dr. Platzbecker and her associates previously reported results from an adjusted analysis showing that patients from the same database with a history of migraine who underwent surgery had an overall 42% increased rate of 30-day readmissions for pain compared with surgery patients who had no migraine history (Cephalagia. 2019 Feb;39[2]:286-95).

Dr. Platzbecker had no commercial disclosures.

On Twitter @mitchelzoler

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