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Am Fam Physician. 2003;67(7):1607

Patients commonly present to the emergency department with headache of benign and primary etiology. Treatments vary greatly, with migraine-type headache being treated most often with parenteral medications and opioids. Meperidine was found to be used more often than dopamine-antagonist antiemetics (e.g., prochlorperazine) or 5-HT receptor antagonists (triptans). Most patients receiving opioids also received less effective antiemetics (e.g., promethazine, hydroxyzine), which lack antiheadache effects. Vinson and associates analyzed the practice patterns of adult benign headache treatment in three unrelated hospital emergency departments.

Reviewing the records of all patients 16 to 65 years of age with a diagnosis of benign headache who received parenteral therapy, a database of treatments and treatment sequences for each patient was compiled. During the four-month study, 993 patients were diagnosed with benign headache. Of this group, 490 patients received parenteral therapy and had complete records, with a low likelihood of intracranial pathology or other non-headache secondary diagnosis, making them eligible for inclusion. Sixty patients made two or more visits to the emergency department during the study period, for a total of 629 visits. On average, each patient received 2.1 different parenteral medications from a range of 20 different medications.

Opioids were used in 47.5 percent of visits, with meperidine being the most common choice. Prochlorperazine and ketorolac followed in second and third places (45.5 and 25.9 percent, respectively). Dihydroergotamine (DHE), sumatriptan, intravenous caffeine, steroids, and benzodiazepines were rarely used. Prochlorperazine was the most common nonopioid parenteral agent used. Diphenhydramine was frequently coadministered to prevent akathisia. Based on diagnosis, patients with migraine were more likely to receive meperidine and less likely to receive prochlorperazine.

The authors conclude that polypharmacy is common in the treatment of persons presenting to the emergency department with isolated, benign headache. A broad range of medications is used, with great variation among emergency departments. Migraine management guidelines that strongly recommend the use of nonopioids, including trip-tans, DHE, and antiheadache antiemetics (e.g., prochlorperazine), cannot offer supporting evidence. Although lack of evidence means that specific recommendations are difficult to make, it is clear that if an antiemetic is to be used, the dopamine-antagonist antiemetics, including droperidol, prochlorperazine, and metoclopramide, are more effective and have better antiheadache effects than promethazine and hydroxyzine.

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