Propofol for migraine in the emergency department: A pilot randomised controlled trial

Abstract

ObjectiveTo test the administration of intravenous (i.v.) propofol at a procedural sedation dose compared to standard therapy for initial management of migraine in the ED.MethodsThis was an open label, randomised controlled pilot trial. Eligible patients were adults with a diagnosis of migraine and planned for treatment with i.v. medications. Patients were randomised to propofol or standard therapy groups. The primary outcome variable was time to discharge (TTD) defined as time from intervention to discharge from the ED. Secondary outcomes were safety of propofol administration and change in pain scores. A reduction of pain by ≥50% or discharge from the ED was defined as favourable. All analyses were performed on an intention‐to‐treat basis.ResultsData from 29 patients were analysed, with 15 patients in the propofol group and 14 patients in the standard therapy group. TTD was significantly lower in the propofol group with median of 290 (interquartile range 162–500) min compared to 554.5 (interquartile range 534–639) min in the standard therapy group (P = 0.021). The hazard ratio for the defined favourable outcome of reduction of pain scores or discharge from the ED was 1.54 (95% CI 0.69–3.41).ConclusionsInitial management of migraine with i.v. propofol at procedural sedation doses significantly reduced TTD compared to standard therapy. We did not detect any significant safety concerns although the study was not adequately powered to detect safety of the intervention and requires validation.

Second‐line interventions for migraine in the emergency department: A narrative review

“…Subsequently, two studies of propofol for migraine have been published. The first was a small, randomized, unblinded study of propofol versus standard care 27 . Propofol was dosed at 1 mg/kg.…”

“…The first was a small, randomized, unblinded study of propofol versus standard care. 27 Propofol was dosed at 1 mg/kg. In this study, pain scores between the groups were comparable, though patients who received propofol were able to be discharged sooner.…”

Comparing treatments in the emergency department: What works for migraine?

“…While not statistically significant, these results suggest chlorpromazine should be considered for patients with severe migraine, while prochlopromazine appears less likely to cause serious adverse events. In reality, ED providers frequently combine therapies such as diphenhydramine, antiemetics, non-steroidal anti-inflammatories, magnesium, anticonvulsants, dihydroergotamine, and even more aggressive therapies such as propofol 9 or ketamine. 10 Given these challenges, here are a few suggestions for what we can do as headache experts to improve the care of migraine in the ED in the future:…”

“…An evidence‐based assessment by Orr et al graded only metoclopramide, prochlorperazine and subcutaneous sumatriptan as Level B recommendations, and dexamethasone as Level B to prevent headache recurrence 8 . In reality, ED providers frequently combine therapies such as diphenhydramine, antiemetics, non‐steroidal anti‐inflammatories, magnesium, anticonvulsants, dihydroergotamine, and even more aggressive therapies such as propofol 9 or ketamine 10 …”

Propofol for migraine: Just because we can, should we?

“…This issue of Emergency Medicine Australia reports the results of a pilot study comparing propofol at procedural sedation doses with standard intravenous therapy for migraine. [5] Although this pilot study has some methodological flaws, let me commend the researchers for undertaking research in this area. From personal experience, I know that research like This article is protected by copyright.…”