Great Evidence Found in Research Against Opioids in the Management of Migraines in the ER

Thursday, June 15, 2017

Prochlorperazine Found Superior to Hydromorphone for Migraine in the Emergency Department

​BY RICHARD ROBINSON

BOSTON—Intravenous prochlorperazine plus diphenhydramine was found to be superior to intravenous hydromorphone for emergency department (ED) management of acute migraine, according to a randomized, double-blind trial presented here in June at the American Headache Society annual meeting.

"We wanted to perform the study because more than one million migraine visits occur in emergency departments annually in the United States, and the majority of these patients are treated with opioids, but there was a dearth of high-quality evidence regarding the appropriateness of opioids in this role," said lead investigator Benjamin Friedman, MD, associate professor of emergency medicine at Albert Einstein College of Medicine in Bronx, NY.

Migraine patients presenting to two New York emergency departments whose physicians had cleared them for participation were randomized to 10 mg prochlorperazine plus 25 mg diphenhydramine or 1 mg hydromorphone, both administered intravenously over five minutes. After one hour, patients could receive a second dose if needed. The primary endpoint was achievement of mild or no headache within two hours and maintenance of relief for 48 hours with no rescue medication.

The study was stopped early, after 127 patients were enrolled, due to superiority of prochlorperazine. Sixty percent of prochlorperazine patients but only 31 percent of the hydromorphone patients achieved the primary endpoint of two-hour headache reduction (number needed to treat=4). Sixty percent of prochlorperazine patients but only 41 percent of hydromorphone patients maintained 48 hours of relief after treatment (number needed to treat=6). Similar numbers of patients in each arm returned to the ED within one month.

"We were surprised at how much better the prochlorperazine patients did — certainly better than we anticipated," Dr. Friedman said. "We think these data should be compelling to any emergency clinician who still uses opioids as a first-line treatment in opioid-naive patients. This now seems inappropriate because patients are less likely to have a good outcome, [and are] more likely to require a rescue medication."

The study demonstrates that "there is no place for intravenous opioids for treatment of acute migraine," commented Peter Goadsby, MD, FAHS, professor of neurology at Kings College London and University of California, San Francisco, and chair of the science program committee of the AHS, who was not involved in the trial.

In addition to being less effective, Dr. Goadsby added, "there is good evidence that opioids reduce responsiveness to triptans," used for acute migraine treatment, "even for a month after a single dose. They are not helpful."

LINK UP FOR RELATED INFORMATION:​

Orr SL, Friedman BW, Christie S, et al. Management of adults with acute migraine in the emergency department: The American Headache Society evidence assessment of parenteral pharmacotherapies. Headache 2016; 56(6):911-940.

Dr. Eric Hastriter practices pediatric headache medicine in Mesa, Arizona. Dr. Hastriter studies, evaluates, diagnoses, and treats conditions that affect the nervous system, specifically relating to head pain. Headache specialist are trained to fully understand and treat such conditions as Chronic Migraine, Chronic Tension Type Headache, New Daily Persistent Headache and many more primary as well as secondary headaches.

I am going to try to keep readers up to date on the latest research into the acute and chronic treatments of migraine. The latest and greatest will be posted and commentary is welcome. Please feel free to leave a message or ask a question about anything you may read in this blog.