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Acute Migraine Treatment in Emergency Settings



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Am Fam Physician. 2014 May 1;89(9):742-744.

  See the full review, clinician summary, consumer summary, and CME activity.

This clinical content conforms to AAFP criteria for continuing medical education (CME). See CME Quiz Questions.

Author disclosure: No relevant financial affiliations.

Key Clinical Issue

What are the comparative benefits and adverse effects of parenteral treatments for adults who present to the emergency department with migraine headaches?

Evidence-Based Answer

Parenteral sumatriptan, metoclopramide, neuroleptics, and nonsteroidal anti-inflammatory drugs (NSAIDs) effectively reduce or eliminate migraine headache pain within two hours. (Strength of recommendation [SOR]: A, based on consistent, good-quality patient-oriented evidence.) Droperidol may provide complete relief better than prochlorperazine. (SOR: B, based on inconsistent or limited-quality patient-oriented evidence.) Migraine recurrence is less likely in patients receiving dexamethasone with abortive therapy. Most adverse effects are minor and self-limiting; however, akathisia is associated with neuroleptics and metoclopramide.

Clinical Bottom Line: Acute Migraine Treatment in Emergency Settings

Ability to achieve pain-free status

Neuroleptics, NSAIDs, and sumatriptan improve the likelihood of achieving pain-free status at various time points after administration vs. placebo. ●●○

Sumatriptan at 30 to 120 minutes (RR = 4.73; 95% CI, 3.77 to 5.94)

Neuroleptics (prochlorperazine, chlorpromazine, and droperidol) at 60 minutes (RR = 3.38; 95% CI, 1.16 to 9.83)

NSAIDs at 60 to 120 minutes (RR = 2.74; 95% CI, 1.26 to 5.98)

More patients report full relief from headaches with droperidol compared with prochlorperazine (RR = 0.81; 95% CI, 0.68 to 0.98). ●●○

The evidence is insufficient to permit conclusions about the likelihood of achieving pain-free status with other treatments.

Ability to provide significant headache relief (complete or partial)

Neuroleptics and sumatriptan provide significant headache relief at various time points after administration vs. placebo. ●●○

Neuroleptics (haloperidol, chlorpromazine, prochlorperazine, and droperidol) at 60 minutes (RR = 2.69; 95% CI, 1.66 to 4.34)

Sumatriptan at 60 minutes (RR = 3.03; 95% CI, 2.59 to 3.54) and at 120 minutes (RR = 2.61; 95% CI, 2.09 to 3.26)

Ability to reduce pain intensity

Pain intensity measurements at time points after administration are reported as the mean difference vs. placebo on a 100-point visual analog scale (in mm).*

Neuroleptics, metoclopramide, opioids, and sumatriptan significantly improve pain intensity at various time points vs. placebo. ●●○

Neuroleptics (chlorpromazine, haloperidol, and prochlorperazine) at 30 minutes to four hours (MD = −46.59 mm; 95% CI, –54.87 to −38.32)

Metoclopramide at 30 to 60 minutes (MD = −21.88 mm; 95% CI, −27.38 to −16.38)

Opioids (meperidine; nalbuphine; tramadol; and hydroxyzine plus nalbuphine) at 45 to 60 minutes (MD = −16.73 mm; 95% CI, –24.12 to −9.33)

Sumatriptan at 30 minutes (MD = −15.45 mm; 95% CI, −19.49 to −11.41)

Neuroleptics (chlorpromazine and prochlorperazine) as a group reduce pain intensity more than metoclopramide (MD = 16.45 mm; 95% CI, 2.08 to 30.83); however, there are no differences in the reduction of pain intensity when metoclopramide and prochlorperazine are compared alone.●○○

There are no significant differences in the reduction in pain between prochlorperazine and droperidol. ●○○

The evidence is insufficient to permit conclusions about the ability of other interventions to reduce migraine headache pain.

From indirect comparisons (not head-to-head trials), there is limited evidence that monotherapy with dihydroergotamine or dihydroergotamine in combination with either prochlorperazine or metoclopramide can reduce pain intensity. ●○○

Ability to prevent recurrence†

Patients receiving dexamethasone plus standard abortive therapy are less likely to report recurrence of pain or headache up to 72 hours after discharge compared with patients receiving placebo plus standard abortive therapy (RR = 0.68; 95% CI, 0.49 to 0.96). ●●○

The rate of headache recurrence within 24 hours is lower with sumatriptan than with placebo (RR = 0.72; 95% CI, 0.57 to 0.90). ●○○

Additional evidence on recurrence rates is too limited to guide clinical decision making.

Adverse effects

The evidence is insufficient to conclude which active treatment results in more or fewer adverse effects.

The odds of developing akathisia after treatment with a neuroleptic agent or metoclopramide are about 10 times greater than with placebo.

The risk of sedation is common after treatment with metoclopramide or prochlorperazine (17% for both).

The most common adverse effects from dihydroergotamine include pain or swelling at the injection site, intravenous site irritation, sedation, digestive issues, nausea or vomiting, and chest symptoms (palpitations, arrhythmia, or irregular heartbeat).

The most common adverse effects of triptans are local reactions. According to the U.S. Food and Drug Administration, there is a risk of coronary vasospasm if sumatriptan is given to patients with known or unknown coronary or vascular risk factors.

NSAIDs and opioids are associated with few short-term adverse effects.


The opinions and assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of the U.S. Army Medical Department or the U.S. Army Service at large.

Address correspondence to Aaron Saguil, MD, MPH, FAAFP, at asaguil@usuhs.edu. Reprints are not available from the authors.

EDITOR'S NOTE: American Family Physician SOR ratings are different from the Agency for Healthcare Research and Quality Strength of Evidence (SOE) ratings.

 

REFERENCES

1. Smitherman TA, Burch R, Sheikh H, Loder E. The prevalence, impact, and treatment of migraine and severe headaches in the United States: a review of statistics from national surveillance studies. Headache. 2013;53(3):427–436.

2. Headache Classification Committee of the International Headache Society (IHS). The International Classification of Headache Disorders. 3rd ed (beta version). Cephalalgia. 2013;33(9):629–808.

3. Goldberg L. The cost of migraine and its treatment. Am J of Manag Care. 2005;11(2 suppl):S62–S67.

4. Agency for Healthcare Research and Quality, Effective Health Care Program. Acute migraine treatment in emergency settings. Clinician research summary. Rockville, Md.: Agency for Healthcare Research and Quality; September 2013. http://effectivehealthcare.ahrq.gov/search-for-guides-reviews-and-reports/?pageaction=displayproduct&productID=1323. Accessed February 20, 2014.

5. Institute for Clinical Systems Improvement. Diagnosis and treatment of headache. https://www.icsi.org/guidelines__more/catalog_guidelines_and_more/catalog_guidelines/catalog_neurological_guidelines/headache/. Accessed February 20, 2014.

6. Evers S, Afra J, Frese A, et al. EFNS guideline on the drug treatment of migraine—revised report of an EFNS Task Force. Eur J Neurol. 2009;16(9):968–981.

The Agency for Healthcare Research and Quality (AHRQ) conducts the Effective Health Care Program as part of its mission to organize knowledge and make it available to inform decisions about health care. A key clinical question based on the AHRQ Effective Health Care Program review is presented, followed by an evidence-based answer and an interpretation that will help guide clinicians in making treatment decisions.

A collection of Implementing AHRQ Effective Health Care Reviews published in AFP is available at http://www.aafp.org/afp/ahrq.


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