Q&A: What do you know about migraine Rx and Tx in the emergency department?
What do you know about migraine Rx and Tx in the ED?According to the American Headache Society (AHS) there are more than 20 different parenteral medications used in US emergency departments to treat acute migraine headache in adults. Until recently, however, there was no evidence-based recommendation (grounded in efficacy and safety) on which of those should be considered first-line therapy.The AHS performed a comprehensive review of the literature, looking at randomized controlled trials of 25 medications, and published an assessment of the results in 2016 in the journal Headache.This short Q&A slide show tests what you migh/might not know about ED migraine management and highlighths the AHS findings, too.
Acetaminophen * Chlorpromazine * Dexketoprofen * Diclofenac * Dihydroergotamine * Dipyrone * Droperidol * Haloperidol * Ketamine * Keterolac * Lidocaine * Lysine clonixinate * Meperidine . . . and more.
1. Approximately how many emergency department (ED) visits are there in the United States each year for the treatment of migraines?
2. In 1998, opioids, including opioid-containing oral analgesic combinations, were administered in what proportion of ED visits for migraine?
Answer: A. More than half (59%) of ED visits for migraine in 1998 included treatment with opioids or opioid- containing analgesics.2
3. Hydromorphone, the most commonly used parenteral agent to treat migraine in 2010, was used in 25% of ED visits, compared with what percentage of visits in 1998?
4. In contrast, use of meperidine to treat migraine in the ED had declined to 7% in 2010 compared with what percentage in 1998?
Answer: D. 37%. Meperidine was used in more than one-third of ED visits to treat migraine headache in 1998.2
5. What percentage of patients who go to the ED for treatment of migraine report obtaining sustained pain relief from the treatment they receive?
6. Which of the parenteral medications above appear to provide the most relief to patients with acute migraines?
Answer: E. Intravenous metoclopramide, intravenous prochlorperazine, and subcutaneous sumatriptan appear to be most likely to provide relief with tolerable side effects. Intravenous diphenhydramine appears to be unlikely to provide much benefit.1
7. What are those most common adverse events associated with the use of intravenous metoclopramide and prochlorperazine?
Answer: E. All of the above. Because of the increased risk of adverse events, patients who have taken ergotamine, a triptan medication, or DHE within the previous 24 hours should not be given subcutaneous sumatriptan.1
9. True or False: Intravenous morphine and hydromorphone appear to be effective treatment for acute migraines.
Answer: B. False. Neither IV morphine or hydromorphone has been shown to provide much benefit in treatment of acute migraine.1
10. Among patients treated for acute migraine in the ED, which medication above appears most likely to prevent headache recurrence?
Answer: B. Intravenous dexamethasone. Data aggregated from a number of placebo-controlled trials found that dexamethasone decreased the frequency of headache recurrence after ED discharge.1
Drugs Currently Being Used to Treat Acute Migraine in US Emergency Departments
1. Friedman BW, West J, Vinson DR, et al. Current management of migraine in US emergency departments: An analysis of the National Hospital Ambulatory Medical Care Survey. Cephalalgia. 2015;35:301-309.
2. 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 pharmacoptherapies. Headache. 2016;56:911-940.