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Despite a range of therapeutic options for treating acute migraine headaches, the use of opioids is still reported to be common practice. This study describes treatment practices in regards to migraines in the ED. It characterizes the prevalence of opioid orders during visits in three different settings, an academic medical center, a non-academic urban ED, and a community ED.Fourteen months of consecutive migraine visits were identified. All medications ordered were separated into first-line and rescue medications. Number of visits, length of stay, door to provider time, and total provider time were compared.A total of 1222 visits were identified. Opioids were ordered in 35.8% of these visits. By facility, opioids were ordered in 12.3% of academic medical center visits, 40.9% of urban ED visits, and 68.6% of community ED visits. This ranged from 6.9% of first-line therapies in the academic center to 69.9% of rescue therapies in the community ED. Of those who received opioids, 36.0% versus 25.1% required rescue medications. Patients who received opioids had more repeat visits, 1.79 versus 1.30. The academic center and urban ED both found greater than 30% decrease in length of stay in visits where opioids were not given.In the face of evidence against opioids for migraines, over one third of patients received them. There was a higher prevalence in the community setting. There were no significant benefits in overall throughput time, however, opioid visits required more rescue medications, increased length of stay, and resulted in more repeat visits.