Rescue Therapy for Acute Migraine, Part 2: Neuroleptics, Antihistamines, and Others

Abstract

Objectives.-This second portion of a 3-part series examines the relative effectiveness of headache treatment with neuroleptics, antihistamines, serotonin antagonists, valproate, and other drugs (octreotide, lidocaine, nitrous oxide, propofol, and bupivacaine) in the setting of an emergency department, urgent care center, or headache clinic.Methods.-MEDLINE was searched using the terms "migraine" AND "emergency" AND "therapy" OR "treatment." Reports were from emergency department and urgent care settings and involved all routes of medication delivery. Reports from headache clinics were only included if medications were delivered by a parenteral route.Results.-Prochlorperazine, promethazine, and metoclopramide, when used alone, were superior to placebo. Droperidol and prochlorperazine were superior or equal in efficacy to all other treatments, although they also have more side effects (especially akathisia). Metoclopramide was equivalent to prochlorperazine and, when combined with diphenhydramine, was superior in efficacy to triptans and non-steroidal anti-inflammatory drugs. Meperidine was inferior to chlorpromazine and equivalent to the other neuroleptics. The overall percentage of patients with pain relief after taking droperidol and prochlorperazine was equivalent to sumatriptan.Conclusions.-Prochlorperazine and metoclopramide are the most frequently studied of the anti-migraine medications in the emergent setting, and the effectiveness of each is superior to placebo. Prochlorperazine is superior or equivalent to all other classes of medications in producing migraine pain relief. Dopamine antagonists, in general, appear to be equivalent for migraine pain relief to the migraine-"specific" medications sumatriptan and dihydroergotamine, although there are fewer studies involving the last two. Lack of comparisons to placebo and the frequent use of combination medications in treatment arms complicate the comparison of single agents to one other.Key words: migraine, emergency, treatment, DHE, triptan, magnesium (Headache 2012;52:292-306) NOTE TO THE READERIn part 1 of this review, results of trials involving triptans, dihydroergotamine, and magnesium as rescue medications for migraine administered in emergency departments, urgent care centers, and headache clinic infusion centers were reviewed. Pertinent information concerning migraine pathophysiology and the methodology commonly used for studies of rescue migraine therapy also were included. This article (part 2) focuses on similar studies involving neuroleptics, antihistamines, serotonin antagonists, valproate, and other assorted medications (octreotide, lidocaine, nitrous oxide, propofol, and bupivacaine). Part 3 will address studies involving opioids, non-steroidal anti-inflammatory drugs, steroids, and post-discharge medications.Explanation of Methodology.-When drugs from 2 different classes of medications were compared,

Targeting TRP Channels For Novel Migraine Therapeutics

“…Lysine acetylsalicylic acid (not available in the United States) and metoclopramide have a moderate level of evidence, while only a low level of evidence exists to support the use of intravenous ketorolac. 22 …”

The Use of a Pediatric Migraine Practice Guideline in an Emergency Department Setting

“…41 Failure rates of treatment, commonly defined as the need for a second rescue drug, headache recurrence within 48 hours, and readmission, range from 10% to 50% with the use of DRAs. 9,11,13,21,[41][42][43][44][45] The admission rates of pediatric patients with migraine headaches are reported in the literature from 3% to 32%. 8,13 We had an admission rate of 7.5%, although we did not evaluate the relapse rate or readmission rate for our patients discharged from the ED.…”

Chronic Migraine

“…106 Metoclopramide or prochlorperazine is frequently used in the emergency setting to effectively abort an acute migraine.…”