Migraine treatment amid intravenous fluid shortages

In the Aftermath of Hurricane Helene in 2024, the healthcare system faces a critical storage of intravenous fluids (IVF) after key production facilities, including Baxter International’s North Cove plant in North Carolina, suspended operations, accounting for about 60% of the nation’s IVF.[1,2] While production is expected to resume by year-end, no timeline exists for a return to prehurricane levels, forcing hospitals to ration IVF use.[2] As a result, many hospitals have employed conservation measures under the assumption that the shortage crisis will continue until the next year with IVF usage dropping 55% since early October.[3] IVF shortage has directly affected neurological treatments, including status migrainosus treatments.[4] Migraines account for over 5 million U.S. emergency visits annually.[5] Due to limited supplies, many patients seeking migraine relief are facing delays in care, particularly in outpatient infusion centers.[4] Outpatient infusion centers offer treatments to refractory and severe headaches for established patients where patients are triaged based on severity and availability. Johnson et al.[6] noted that the average cost of an outpatient infusion center visit, ED visit, and inpatient admission for headache were $1,080, $1,451, and $7,595, respectively. The delay in outpatient migraine treatment increases healthcare resource usage through higher triage/answering service calls, emergency room visits, and even admissions. We aim to optimize migraine treatment and policy improvement amidst the IVF shortage. In the outpatient setting, IVF boluses and infusions are common practices in the treatment status of migrainosus and medication-refractory migraines. One such protocol includes 1 L IVF, 2 g IV magnesium sulfate, IV ketorolac 15 mg, and/or IV metoclopramide 10 mg for managing status migrainosus.[5,7] There is also an increasing rise of infusion-based treatments such as eptinezumab-jjmr (Vyepti) and dihydroergotamine.[8] These outpatient-based infusion clinics offer acute migraine treatment while decreasing headache patient volume seeking ED care and time to treatment.[9] However, the rationing of IVF limits these treatments with hospitals and infusion clinics struggling to accommodate elective procedures.[9] Patients are experiencing delays or cancellations of their Vyepti infusions due to IVF shortage, despite Vyepti requiring only 100cc IVF every 3 months.[4] The displaced patients lead to unnecessary ED visits, higher costs, longer wait times, and unnecessary radiographic scans.[9] Outpatient infusion clinics enable patients to manage their treatment effectively, reducing migraine severity and preventing future hospital admissions.[9] The IVF shortage has highlighted the value of outpatient infusion clinics in migraine treatment and prevention. However, there are also opportunities to improve migraine treatment. Clinicians have over 30 migraine treatment options, resulting in varied practices nationwide.[5] IVF boluses are given for about 40% of headaches in the ED, with increasing usage over the last 20 years.[10] Balbin et al. conducted a post hoc analysis of 570 patients from 4 ED-base migraine clinical trials which showed that IVFs did not improve acute migraine symptoms (odds ratio [OR], 0.8; 95% confidence interval, 0.4–1.5; P = 0.52) and that the probability of migraine attack recurrence after discharge from the emergency department is about 33%.[10] Reducing or eliminating IVF boluses for migraine treatment could reduce unnecessary IVF usage. In addition, enteral treatment options should be considered first-line therapy for patients who can tolerate them, potentially conserving IVF for cases requiring intravenous administration. Effective enteral options such as acetaminophen, NSAIDs, triptans, and Calcitonin gene-related peptide (CGRP) inhibitors (e.g., rimegepant, and ubrogepant) and even oral rehydration should be prioritized. Chiang et al.[11] performed a retrospective analysis of over 10 million migraine attack records and compared 25 acute migraine medications. They found that triptans (OR 4.8), ergots (OR 3.02), and antiemetics (OR 2.67) are the most effective migraine medications. However, for the best effect, abortive medication should be taken immediately upon migraine onset. Future research should evaluate oral “migraine cocktail” regimens as IV alternatives, with neuromodulation as a promising area for future exploration. The recent hurricane disruptions on migraine care necessitate refreshed awareness, innovation, and adaptation to an area of medicine that has been exposed to recent natural disasters. Eliminating unnecessary IVF within migraine treatments can help to reprioritize fluids to evidence-based practices such as outpatient infusion medications where there have already been evidence in delays in care. In addition, developing oral migraine treatment protocol would serve to further advance the field of migraine treatments. Without such adjustments, the burden on healthcare may increase due to inadequate symptom relief, leading to higher rates of bounce-back visits and escalating overall demand on already strained emergency services. The need for IVF increases each year due to the surging aging population and advances in medical innovation.[10] To prevent future similar IVF shortages, there must be further diversification of production and supply chains of critical medical resources. Relying heavily on a limited number of production facilities, such as the Baxter International plant in North Carolina, has left the healthcare system vulnerable to regional disruptions, as seen with Hurricane Helene. A policy change to establish geographically diverse production sites could reduce the risk of widespread shortages and improve resilience in emergency situations. The current IVF shortage has caused a nationwide emergency that has resulted in a federal response to temporarily authorize importation from Canada, China, Ireland, and the U.K.[3] The Food and Drug Administration (FDA) released guidance providing new flexibilities related to compounding IV solutions, making it easier for hospitals and other facilities to make their own IV solutions. The FDA also implemented restrictions to prevent price gouging and permitted airlift of new product.[12] In addition, the government enacted the Defense Production Act to help Baxter rebuild and restore production.[12] However, reactionary efforts are inefficient in comparison to preventative measures. Investing in redundant supply networks and encouraging alternative manufacturing partnerships would ensure that essential resources like IVF remain available in the event of localized disasters. Geographic diversification would also alleviate transportation as delivery across fragmented markets was affected by the recent shortage.[3] By recognizing the current shortage as a call to action, policymakers and healthcare leaders can proactively address supply vulnerabilities, preventing similar crises in the future and strengthening the healthcare infrastructure. Author contributions WZ: Concepts, design, definition of intellectual content, literature search, data acquisition, data analysis, manuscript preparation, editing and review; AZ: Concepts, design, definition of intellectual content, data acquisition, manuscript editing and review. Ethical policy and institutional review board statement Not applicable. Data availability statement Data sharing is not applicable to this article as no datasets were generated and/or analyzed during the current study. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

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