The Efficacy of Propofol vs. Subcutaneous Sumatriptan for Treatment of Acute Migraine Headaches in the Emergency Department: A Double‐Blinded Clinical Trial

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).

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“…We identified two randomized studies of propofol . In a class 2 study, 90 patients were randomized to propofol IV or sumatriptan 6 mg SC .…”

Section: Resultsmentioning

confidence: 99%

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

et al. 2016

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“…Nine studies were included for a total of 290 patients (Figure ) . These studies are summarized in Table and consisted of five case reports or series ( n = 5), one retrospective cohort study ( n = 1), and three randomized controlled trials ( n = 3).…”

Section: Resultsmentioning

confidence: 99%

“…Moshtaghion et al conducted a randomized, double‐blind, active controlled trial to evaluate the efficacy of propofol for acute migraine treatment compared to sumatriptan in adults (age 18 to 45 years) presenting to the ED. Patients were randomized to receive propofol ( n = 45) as a 30‐ to 40‐mg IV bolus followed by a 10‐ to 20‐mg IV bolus every 3 to 5 minutes for a maximum dose of 120 mg or sumatriptan ( n = 45) 6 mg subcutaneously once followed by the same dose after 1 hour if the pain score was reduced by less than 4 points.…”

Section: Resultsmentioning

confidence: 99%

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Propofol for Treatment of Acute Migraine in the Emergency Department: A Systematic Review

Piatka

Beckett

2019

Academic Emergency Medicine

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Objectives Propofol has not been extensively studied as an acute migraine therapy; however, based on the limited evidence from outpatient and inpatient settings, propofol has been proposed as an option for patients who present to the emergency department (ED). The purpose of this review was to evaluate the existing literature regarding the safety and efficacy of propofol for acute migraine treatment in the ED. Methods A systematic review of clinical studies of propofol treatment for acute migraine in the ED was performed using Preferred Reporting Items for Systematic Review and Meta‐Analysis (PRISMA) guidelines. Trials were identified through PubMed, Google Scholar, clinical trial registries, research registries, and key journals through May 2019. A modified Jadad scoring system was used to assess the methodologic quality of the included randomized controlled trials, and the Newcastle‐Ottawa Scale was used for the retrospective cohort study. Results Nine studies, including five case reports or series, one retrospective cohort study, and three randomized controlled trials, consisting of 290 patients, were reviewed. All studies in adults reported propofol to be an effective therapy for migraine, but the strength of these results was limited by dosing variations, small sample sizes, and limited generalizability. Pediatric studies produced mixed results. Conclusions Propofol may be an effective rescue therapy for patients presenting to the ED for acute migraine, but its place in therapy based on the limited available evidence is unknown. The safety of propofol for migraine management in the ED has not been adequately examined.

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“…68 Ketamine currently has grade D recommendation for its acute use in conditions such as migraine. 72 Lidocaine has utility both as an anesthetic as well as an antiarrhythmic. 42 ED-administrations of low dose propofol led to greater pain reduction in pediatric patients with migraine when compared to patients who received a standard combination of prochlorperazine, NSAID, and diphenhydramine (80.1% vs 61.1%, P < .05).…”

Section: Expert Opinionmentioning

confidence: 99%

Status Migrainosus in Children and Adults

2019

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The Efficacy of Propofol vs. Subcutaneous Sumatriptan for Treatment of Acute Migraine Headaches in the Emergency Department: A Double‐Blinded Clinical Trial

Abstract: Propofol is equally suitable as sumatriptan for the acute treatment of migraine headaches in an emergency department setting. Moreover, the use of propofol avoids some of the adverse side effects of sumatriptan while providing better control of nausea and vomiting.

Cited by 32 publications

References 12 publications

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

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

Propofol for Treatment of Acute Migraine in the Emergency Department: A Systematic Review

Status Migrainosus in Children and Adults

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