Migraine Treatment in the Emergency Department: Alternatives to Opioids and their Effectiveness in Relieving Migraines and Reducing Treatment Times

Dodson, Haley; Bhula, Jay; Eriksson, Sven; Nguyen, Khoa D.

doi:10.7759/cureus.2439

Cited by 14 publications

(23 citation statements)

References 16 publications

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“…13 Magnesium sulfate has been used to effectively treat acute headaches of various etiologies including migraines, cluster headache, 12,37 chronic intractable headache, 12 and even post-concussive headache. 6 Studies of treatment efficacy have yielded inconsistent results. 38,39 Why it is Important to Do this Review.-Medical practice has shifted away from the use of opiatetype medications for the treatment of non-traumatic headaches.…”

Section: Introductionmentioning

confidence: 99%

Intravenous Magnesium Sulfate to Treat Acute Headaches in the Emergency Department: A Systematic Review

et al. 2019

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Introduction Non‐traumatic headaches comprise up to 4% of all emergency department (ED) visits. Current practice is moving toward multimodal analgesia regimens that limit narcotic use. Objective The objective of this systematic review is to address the following research question: In patients with non‐traumatic headaches (Population), does administration of intravenous magnesium sulfate (Intervention) compared to placebo, corticosteroids, dopamine antagonists, ergot alkaloids, non‐steroidal anti‐inflammatory drugs (NSAIDs), triptans, or usual care result in better pain control, lower rate of recurrence at 24 hours, lower requirements for rescue analgesia, and less adverse medication effects (Outcomes)? Methods Scholarly databases and relevant bibliographies were searched, as were clinical trial registries and relevant conference proceedings to limit publication bias. Studies were not limited by date, language, or publication status. Inclusion criteria were: (1) randomized clinical trial (RCT), (2) patients age ≥18 years, (3) non‐traumatic headache, (4) patients treated in ED or an outpatient acute care treatment center, and (5) magnesium sulfate administered intravenously (IV). Eligible comparison groups included: placebo, conventional therapy, dopamine antagonist, NSAID, corticosteroid, ergot alkaloid, or triptans. Results Out of 4018 identified references, 7 RCTs (545 participants) that treated migraine headaches (n = 6) and benign non‐traumatic headaches (n = 1) met inclusion criteria. Pain intensity was improved with magnesium sulfate vs comparators at 60‐120 minutes, but not at earlier time points. Result for the endpoint of pain reduction by 50% were conflicting as 3 studies reported that headache was improved, unchanged, and less with magnesium sulfate. Complete pain relief was improved with magnesium sulfate in 1 study, and in the migraine with aura (MA) subgroup in another. The need for rescue analgesia at any point was improved with magnesium sulfate in 1 study, and in the MA subgroup in another. Twenty‐four‐hour headache recurrence was improved with magnesium sulfate in 1 study, but unchanged in a second. The intended meta‐analysis was not performed due to the clinical heterogeneity among studies. Conclusion While we cannot draw a firm conclusion on the efficacy or benefit of intravenous magnesium sulfate in the treatment of acute non‐traumatic headaches, the existing evidence indicates potential benefits in pain control beyond 1 hour, aura duration, and need for rescue analgesia.

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Section: Introductionmentioning

confidence: 99%

Intravenous Magnesium Sulfate to Treat Acute Headaches in the Emergency Department: A Systematic Review

et al. 2019

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“…Migraine headache results in over 1 million emergency department (ED) visits per year in the United States . Several treatments have been offered to treat the headache . Prochlorperazine has been tested in randomized trials and, despite adverse effects such as dystonic reactions, several societies recommend its use …”

Section: Narrativementioning

confidence: 99%

“…[1][2][3] Several treatments have been offered to treat the headache. [4][5][6] Prochlorperazine has been tested in randomized trials and, despite adverse effects such as dystonic reactions, several societies recommend its use. 4,6 The systematic review and meta-analysis summarized here evaluated trials of adult patients with acute migraine who were randomized to receive prochlorperazine, placebo, or a comparator agent.…”

Section: Efficacy Endpoints Resolution Of Headache or Reduced Severitymentioning

confidence: 99%

Prochlorperazine for Treatment of Acute Migraines in Adults

Long

Koyfman

Gottlieb

2019

Academic Emergency Medicine

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“…In recent years, extensive efforts have been made to prevent and treat migraine headaches and there are several clinical guidelines on the management of acute migraine . In this regard, several drugs are available for acute treatment of migraine in the ED, including nonsteroidal antiinflammatory drugs (NSAIDs) such as ketorolac; 100% oxygen; opioids such as meperidine, tramadol, hydromorphone, and nalbuphine; triptans such as sumatriptan; anesthetics such as ketamine and lidocaine; dopamine receptor antagonists such as metoclopramide; phenothiazines such as prochlorperazine and chlorpromazine; and ergot alkaloids such as dihydroergotamine and ergotamine . Nevertheless, regarding the optimal therapy for aborting the acute migraine attack, there are significant practical differences among EDs …”

Section: Introductionmentioning

confidence: 99%

“…Previous studies have recommended intravenous prochlorperazine (PCP) for the acute treatment of migraine; however, their recommendations were based on the limited number of randomized clinical trials and observational studies. Recently, several trials have examined the efficacy of PCP on aborting migraine attacks or reducing the severity of migraine headache in the ED and found controversial results along with some serious adverse events such as extrapyramidal symptoms . Regarding the efficacy and safety of PCP for management of adult patients with migraine, a current systematic review and meta‐analysis of the available treatments is needed.…”

Section: Introductionmentioning

confidence: 99%

The Efficacy and Safety of Prochlorperazine in Patients With Acute Migraine: A Systematic Review and Meta‐Analysis

et al. 2019

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Objective The aim of this review was to evaluate the efficacy and safety of prochlorperazine (PCP) in patients with acute migraine headache in the emergency department (ED). Methods Electronic databases (Medline, Scopus, Web of Science, and Cochrane) were searched for randomized clinical trials that investigated the effect of PCP on headache relief. The outcomes were the number of patients without headache or with reduced headache severity, the number of adverse events, and the need for rescue analgesia. Results From 450 citations, 11 studies (n = 771) with 15 comparison arms met the inclusion criteria. Overall, PCP was more effective than placebo (OR = 7.23; 95% CI = 3.82‐3.68), metoclopramide (OR = 2.89; 95% CI = 1.42‐5.86), and other active comparators (OR = 3.70; 95% CI = 2.41‐5.67) for headache relief. The odds ratio of experiencing adverse events with PCP compared with placebo was 5.79 (95% CI = 2.43‐13.79). When PCP compared with other active comparators, no statistical difference was found regarding the overall number of adverse events (OR = 1.88; 95% CI = 0.99‐3.59). However, PCP significantly increased the odds of akathisia/dystonia (OR = 2.55; 95% CI = 1.03‐6.31). The request for rescue analgesia was significantly lower in the PCP group compared with other groups (16% vs 84%; OR = 0.16; 95% CI = 0.09‐27). Conclusions For adult patients with acute migraine, PCP could effectively abort the acute attack and reduce the request for rescue analgesia in the ED. However, compared with placebo, PCP could increase the risk of adverse events.

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Migraine Treatment in the Emergency Department: Alternatives to Opioids and their Effectiveness in Relieving Migraines and Reducing Treatment Times

Cited by 14 publications

References 16 publications

Intravenous Magnesium Sulfate to Treat Acute Headaches in the Emergency Department: A Systematic Review

Intravenous Magnesium Sulfate to Treat Acute Headaches in the Emergency Department: A Systematic Review

Prochlorperazine for Treatment of Acute Migraines in Adults

The Efficacy and Safety of Prochlorperazine in Patients With Acute Migraine: A Systematic Review and Meta‐Analysis

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