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ANAHEIM, Calif. -- Rural patients were more likely to use the emergency department (ED) and receive opioid analgesics for migraine, a cross-sectional epidemiologic study showed.

The national rural rate of ED utilization for migraine was 41.8 per 10,000 population compared with a national non-rural rate of 23.4 per 10,000 population, reported Christian Rhudy, PharmD, MBA, of the University of Kentucky Healthcare in Lexington.

Notably, the rate of ED utilization for migraine among residents of the Kentucky Appalachian region was 47.4 per 10,000 population, Rhudy said during the American Society of Health-System Pharmacists midyear meeting.

"Seeing how significantly differently the Appalachian population was using the ED for chronic migraines is a pretty stark difference, because ... those patients should be more closely managed in the outpatient setting," Rhudy told MedPage Today.

Rural patients were also prescribed opioids for migraine at significantly higher rates, at 14.6% of ED visits compared with 8% of non-rural ED visits in 2019 (P<0.001).

Simply getting to a clinic or other facility can be a barrier for rural patients, Rhudy said. "I work at UK [University of Kentucky], and to get to Appalachia, it's probably about 3 hours' distance, so there's just not a lot of specialty care, especially neurology care, between here and there."

He said a number of factors could have led to the relatively higher opioid prescription rates. "There might not be as much experience managing migraines [in rural EDs]," he noted. "But I think the other part of it might be they are legitimately having worse migraines because they're not on outpatient prophylaxis medications."

Migraine is considered a disabling condition, affecting almost 16% , and are the fifth most common reason for ED visits. Along with headache, they also cost emergency departments around . Evidence supporting the use of is limited.

"I'm surprised that opiates were frequently used in rural areas," Zhen Wang, PhD, of the Mayo Clinic in Rochester, Minnesota, who was not involved in the study, told MedPage Today. "Opiates are not as effective compared to ... treatments [like] NSAIDs [nonsteroidal anti-inflammatory drugs] and triptans," in addition to newer therapies.

However, NSAIDs, antiemetics, and steroids were all prescribed more commonly than opioids for migraine in both rural and non-rural ED visits.

"There are rural disparities in these disease states, and they're pronounced in Appalachia," Rhudy said. "So, taken in the greater context, these results aren't super surprising, but we've got to do more to address the needs of this population."

For this study, the researchers used data from the Healthcare Cost and Utilization Project Nationwide Emergency Department Sample and the Kentucky State Emergency Department Database from 2019, and classified ED encounters according to the National Center for Health Statistics (NCHS) Urban-Rural Codes.

They included 810,388 visits with a primary diagnosis code for migraine, and excluded encounters with a missing NCHS Urban-Rural code. Mean patient age was 38, 80.2% were women, and 62% were white. Rural patients were more likely to be white and to have lower incomes than the overall and non-rural patients.

A limitation of the study was the lack of location-specific geographic information for the national-level data.

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