Are butyrophenones effective for the treatment of primary headache in the emergency department?

Abstract

Objectives: Butyrophenones have been reported to provide effective migraine relief in the emergency department (ED). We conducted a systematic review of the evidence for their use in the ED. Data source: We searched the Cochrane, Medline, Embase, and CINAHL databases. Study selection: Included studies were randomized trials of a parenteral butyrophenone (droperidol, haloperidol) versus placebo or a comparator in migraine or benign headache with results available in English. Study quality was determined using the Jadad score. Six articles were included. Data extraction: Primary outcomes were subjective or objective headache relief (. 50% improvement in visual analogue scale scores). Secondary outcomes included side effects. We reported pooled odds ratios (ORs) with their 95% confidence intervals (CIs) for subjective or objective headache relief for butyrophenones versus placebo or comparator agents. Data synthesis: Three studies reported subjective headache relief with a butyrophenone versus placebo or meperidine in migraine. Two studies reported objective headache relief with droperidol versus prochlorperazine, whereas one study compared droperidol versus olanzapine in benign headache. The pooled OR for subjective headache relief was 8.08 (95% CI 1.54-42.30) for a butyrophenone versus placebo, whereas it was 1.50 (95% CI 0.33-6.77) for droperidol versus meperidine in migraine. The pooled OR for objective headache relief was 2.96 (95% CI 1.36-6.43) for droperidol versus prochlorperazine in benign headache. Rates of side effects were 10 to 45%; akathesia and sedation were the most common. Conclusions: Butyrophenones are effective for the relief of migraine or benign headache. However, adverse effects make it difficult to recommend butyrophenones above agents with similar effectiveness and fewer problems. RÉ SUMÉObjectif : Il a é té signalé que les butyrophé nones soulageaient les migraines dans les services d'urgence. Nous avons procé dé à une analyse systé matique sur leur utilisation à l'urgence. Source des donné es : Nous avons interrogé les bases de donné es Cochrane, Medline, Embase et CINAHL. Sé lection des é tudes : Nous avons retenu les essais randomisé s d'un butyrophé none parenté ral (dropé ridol, halopé ridol) contre un placebo ou un comparateur en cas de migraine ou de cé phalé e bé nigne. Les ré sultats devaient ê tre disponibles en anglais. Nous avons é valué la qualité des essais selon le score de Jadad. Six articles ont é té retenus. Extraction des donné es : Les principaux critè res d'é valuation é taient le soulagement subjectif ou objectif de maux de tê te (. 50 % d'amé lioration selon l'é chelle visuelle analogique). Les critè res secondaires d'é valuation é taient entre autres les effets secondaires. Nous avons inclus les rapports de cotes combiné s (RC) avec intervalle de confiance à 95 % (IC) pour le soulagement subjectif ou objectif de maux de tê te pour le groupe butyrophé nones par rapport au groupe placebo ou autres comparateurs. Synthè se des donné es : Trois é tudes ont signal...

The Use of Very-Low-Dose Methadone for Palliative Pain Control and the Prevention of Opioid Hyperalgesia

“…Haloperidol was the most common adjuvant medication prescribed, on a scheduled and as-needed basis, due to its NMDA-blocking effects and its relief of symptoms associated with terminal disease. [41][42][43][44] Our approach of using low-dose methadone for palliative pain management offers the potential for large cost savings compared to more standard practices. The average total medication cost on our service was $2.76 per patient per day.…”

“…21,55,56,57 Nonopioid adjuvant medications have not received much attention in palliative pain management, and do not traditionally include haloperidol for pain despite its potential NMDA-blocking effects. 17,[41][42][43][44] The traditional approach of opioid dose escalation has paradoxically resulted in a decrease in analgesic effect, mediated by two related mechanisms: desensitization of the antinociceptive opioid pathway due to receptor tolerance, and sensitization of the pronociceptive NMDA pathway as a compensatory response to opioid receptor stimulation. [18][19][20][21]27,[58][59][60][61][62][63] This syndrome of opioid-induced hyperalgesia results in an increased sensitivity to pain that is proportional to the dose and strength of the opiate used.…”

“…26 Haloperidol was the primary nonopioid medication used, because evidence suggests that it decreases pain sensitivity, possibly through NMDA inhibition. [41][42][43][44] Patients who were imminently dying received regularly scheduled oral or parenteral opiates, sedatives, and neuroleptics, as needed. Those on methadone continued to receive the drug sublingually.…”

A Neurologist’s Guide to Acute Migraine Therapy in the Emergency Room

“…First, opioids are not as effective in the treatment of acute migraine as other agents, such as dihydroergotamine (DHE), 22 ketorolac, 22 butyrophenones, and the phenothiazines with more side effects. 8,[23][24] In a study comparing treatment with chlorpromazine and meperidine, chlorpromazine was more effective and patients receiving meperidine were more likely to need rescue medication. 8 Opioids may also render acute migraine medications, such as triptans, less effective 24 and may impair the effectiveness of migraine preventives.…”

Clinical Pharmacist Services in the Emergency Department

“…17 In benign headaches, droperidol was superior to prochlorperazine at a dose of 2.5 mg given intravenously or 5 mg given intramuscularly. 18 A 2011 systematic review of 3 studies by Leong and Kelly 19 confirmed that droperidol was more effective than opioids or prochlorperazine for headaches, without an increase in adverse events.…”