Management of Adults With Acute Migraine in the Emergency Department: The American Headache Society Evidence Assessment of Parenteral Pharmacotherapies

Abstract

Objective.-To provide evidence-based treatment recommendations for adults with acute migraine who require treatment with injectable medication in an emergency department (ED). We addressed two clinically relevant questions: (1) Which injectable medications should be considered first-line treatment for adults who present to an ED with acute migraine? (2) Do parenteral corticosteroids prevent recurrence of migraine in adults discharged from an ED?Methods.-The American Headache Society convened an expert panel of authors who defined a search strategy and then performed a search of Medline, Embase, the Cochrane database and clinical trial registries from inception through 2015. Identified articles were rated using the American Academy of Neurology's risk of bias tool. For each medication, the expert panel determined likelihood of efficacy. Recommendations were created accounting for efficacy, adverse events, availability of alternate therapies, and principles of medication action.Results/Conclusions.-The search identified 68 unique randomized controlled trials utilizing 28 injectable medications. Of these, 19 were rated class 1 (low risk of bias), 21 were rated class 2 (higher risk of bias), and 28 were rated class 3 (highest risk of bias). Metoclopramide, prochlorperazine, and sumatriptan each had multiple class 1 studies supporting acute efficacy, as did dexamethasone for prevention of headache recurrence. All other medications had lower levels of evidence.Recommendations.-Intravenous metoclopramide and prochlorperazine, and subcutaneous sumatriptan should be offered to eligible adults who present to an ED with acute migraine (Should offer-Level B). Dexamethasone should be offered to these patients to prevent recurrence of headache (Should offer-Level B). Because of lack of evidence demonstrating efficacy and concern about sub-acute or long-term sequelae, injectable morphine and hydromorphone are best avoided as first-line therapy (May avoid-Level C).

Metoclopramide for Acute Migraine Treatment in the Emergency Department: An Effective Alternative to Opioids

“…One such effect is tardive dyskinesia, which involves the involuntary movement of the tongue, extremities, and face usually associated with long-term use of antidopaminergic drugs. However, since the expected treatment regimen for acute migraines only involves the ED setting, no such events have been reported [22]. In contrast to other recommended treatments, the adverse effect profile of metoclopramide is less worrisome than that of triptans (hypertensive crisis and myocardial infarction), which is also highly used in the ED setting [23-24].…”

Headache in the Emergency Room

“…49 The researchers identified all randomized studies comparing injectable medications to either placebo or control for the treatment of acute migraine in adults. Tiered recommendations for use of medications in the ER setting were developed based on strength of the study and the medication's efficacy and side effect profile.…”

“…Tiered recommendations for use of medications in the ER setting were developed based on strength of the study and the medication's efficacy and side effect profile. 49 Despite not offering Level A, or must offer, recommendation for any drug, the authors determined that IV metoclopramide, prochloperazine and subcutaneous sumatriptan were in the category of should offer (Level B) to patients as first line if no contraindications exist. 49 If these medications are contraindicated, Level C-backed evidence, or may offer, recommends the use of IV acetaminophen, acetylsalicylic acid, dexketoprofen, diclofenac, ketorolac, valproate, and parenteral chlorpromazine, droperidol, or haloperidol.…”

“…49 Narcotics, such as morphine and hydromorphone, are not recommended due to lack of their evidence in regards to efficacy, as well as concerns of the potential for dependence or addiction. 49 For pregnant women, the use of triptans is controversial, along with NSAIDs, which can cause miscarriage or malformation.…”

“…49 Narcotics, such as morphine and hydromorphone, are not recommended due to lack of their evidence in regards to efficacy, as well as concerns of the potential for dependence or addiction. 49 For pregnant women, the use of triptans is controversial, along with NSAIDs, which can cause miscarriage or malformation. 50 Although acetaminophen has long been considered safe for use in pregnancy, a new study has linked its use in pregnancy to risk of attention deficit hyperactivity disorder (ADHD), where the effect appears to be related to quantity of acetaminophen used.…”