Rescue Therapy for Acute Migraine, Part 3: Opioids, NSAIDs, Steroids, and Post‐Discharge Medications

Abstract

Objective.-The final section of this 3-part review analyzes published reports involving the acute treatment of migraine with opioids, non-steroidal anti-inflammatory drugs (NSAIDs), and steroids in the emergency department (ED), urgent care, and headache clinic settings, as well as post-discharge medications. In the Conclusion, there is a general discussion of all the therapies presented in the 3 sections.Method.-Using the terms ("migraine" AND "emergency") AND ("therapy" OR "treatment"), the author searched MEDLINE for reports from ED and urgent care settings that involved all routes of medication delivery. Reports from headache clinic settings were included only if medications were delivered by a parenteral route.Results.-Seventy-five reports were identified that compared the efficacy and safety of multiple acute migraine medications for rescue. Of the medications reviewed in Part 3, opioids, NSAIDs, and steroids all demonstrated some effectiveness. When used alone, nalbuphine and metamizole were superior to placebo. NSAIDs were inferior to the combination of metoclopramide and diphenhydramine. Meperidine was arguably equivalent when compared with ketorolac and dihydroergotamine (DHE) but was inferior to chlorpromazine and equivalent to the other dopamine antagonists. Steroids afford some protection against headache recurrence after the patient leaves the treatment center.Conclusions.-All 3 opioids most frequently studied -meperidine, tramadol, and nalbuphine -were superior to placebo in relieving migraine pain, although meperidine combined with promethazine was not. Opioid side effects included dizziness, sedation, and nausea. With ketorolac being the most frequently studied drug in the class, NSAIDs were generally well tolerated, and they may provide benefit even when given late in the migraine attack. The rate of headache recurrence within 24-72 hours after discharge from the ED can be greater than 50%. Corticosteroids can be useful in reducing headache recurrence after discharge. As discussed in Parts 1, 2, and 3, there are effective medications for provider-administered "rescue" in all the classes discussed. Prochlorperazine and metoclopramide are the most frequently studied of the anti-migraine medications in the emergent setting, and their effectiveness is superior to placebo. Prochlorperazine is superior or equivalent to all other classes of medications in migraine pain relief. Although there are fewer studies involving sumatriptan and DHE, relatively "migrainespecific" medications, they appear to be equivalent to the dopamine antagonists for migraine pain relief. Lack of comparisons with placebo and the frequent use of combinations of medications in treatment arms complicate the comparison of single agents to one another. When used alone, prochlorperazine, promethazine, metoclopramide, nalbuphine, and metamizole were superior to placebo. Droperidol and prochlorperazine were superior or equal in efficacy to all other treatments, although they also are more likely to produce side effects that are diffic...

Controversies in migraine treatment: opioids should be avoided

“…Moreover, among studies about the efficacy of opioids as rescue medication for acute migraine in EDs recently revised, only one evidenced a superiority of meperidina 75 mg i.m. versus ketorolac 30 mg i.m., three reported superiority of competitors and eight reported similar results for opioids versus competitors such as DHE, metoclopramide, chlorpromazine, droperidol, and ketorolac [5]. In any case, opioids did not adequately restore the patient's ability to function.…”

“…Use of opioids for treatment of migraine is controversial. Despite evidence-based guidelines do not recommend opioids as first-line treatment of migraine attacks [2][3][4], and no randomized controlled trial has shown any significant effect of opioids on migraine attacks when pain-free was the primary end-point of the study [5], their use in clinical practice [6][7][8] and, even more, in emergency departments (EDs) is very large, especially in USA and Canada [9,10]. Moreover, among studies about the efficacy of opioids as rescue medication for acute migraine in EDs recently revised, only one evidenced a superiority of meperidina 75 mg i.m.…”

The Results of Greater Occipital Nerve Block Applied for Migraine Headache

“…[4,5] Periferal sinir blokları tedaviye dirençli kronik migren hastalarında gittikçe artan miktarda kullanılmaktadır. İlk defa 1961 yılında Kerr beyin sapında C1-C2'den gelen sinirler ile trigeminal…”

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