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Robblee J. Breaking the cycle: unraveling the diagnostic, pathophysiological and treatment challenges of refractory migraine. Front Neurol 2023; 14:1263535. [PMID: 37830088 PMCID: PMC10565861 DOI: 10.3389/fneur.2023.1263535] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Accepted: 09/11/2023] [Indexed: 10/14/2023] Open
Abstract
Background Refractory migraine is a poorly described complication of migraine in which migraine has chronified and become resistant to standard treatments. The true prevalence is unknown, but medication resistance is common in headache clinic patient populations. Given the lack of response to treatment, this patient population is extremely difficult to treat with limited guidance in the literature. Objective To review the diagnostic, pathophysiological, and management challenges in the refractory migraine population. Discussion There are no accepted, or even ICHD-3 appendix, diagnostic criteria for refractory migraine though several proposed criteria exist. Current proposed criteria often have low bars for refractoriness while also not meeting the needs of pediatrics, lower socioeconomic status, and developing nations. Pathophysiology is unknown but can be hypothesized as a persistent "on" state as a progression from chronic migraine with increasing central sensitization, but there may be heterogeneity in the underlying pathophysiology. No guidelines exist for treatment of refractory migraine; once all guideline-based treatments are tried, treatment consists of n-of-1 treatment trials paired with non-pharmacologic management. Conclusion Refractory migraine is poorly described diagnostically, its pathophysiology can only be guessed at by extension of chronic migraine, and treatment is more the art than science of medicine. Navigating care of this refractory population will require multidisciplinary care models and an emphasis on future research to answer these unknowns.
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Affiliation(s)
- Jennifer Robblee
- Department of Neurology, Dignity Health, St Joseph’s Hospital and Medical Center, Lewis Headache Clinic, Barrow Neurological Institute, Phoenix, AZ, United States
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2
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Yang S, Orlova Y, Lipe A, Boren M, Hincapie-Castillo JM, Park H, Chang CY, Wilson DL, Adkins L, Lo-Ciganic WH. Trends in the Management of Headache Disorders in US Emergency Departments: Analysis of 2007-2018 National Hospital Ambulatory Medical Care Survey Data. J Clin Med 2022; 11:jcm11051401. [PMID: 35268492 PMCID: PMC8910868 DOI: 10.3390/jcm11051401] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Revised: 02/18/2022] [Accepted: 02/28/2022] [Indexed: 12/10/2022] Open
Abstract
We examined trends in management of headache disorders in United States (US) emergency department (ED) visits. We conducted a cross-sectional study using 2007−2018 National Hospital Ambulatory Medical Care Survey data. We included adult patient visits (≥18 years) with a primary ED discharge diagnosis of headache. We classified headache medications by pharmacological group: opioids, butalbital, ergot alkaloids/triptans, acetaminophen/nonsteroidal anti-inflammatory drugs (NSAIDs), antiemetics, diphenhydramine, corticosteroids, and intravenous fluids. To obtain reliable estimates, we aggregated data into three time periods: 2007−2010, 2011−2014, and 2015−2018. Using multivariable logistic regression, we examined medication, neuroimaging, and outpatient referral trends, separately. Among headache-related ED visits, opioid use decreased from 54.1% in 2007−2010 to 28.3% in 2015−2018 (Ptrend < 0.001). There were statistically significant increasing trends in acetaminophen/NSAIDs, diphenhydramine, and corticosteroids use (all Ptrend < 0.001). Changes in butalbital (6.4%), ergot alkaloid/triptan (4.7%), antiemetic (59.2% in 2015−2018), and neuroimaging (37.3%) use over time were insignificant. Headache-related ED visits with outpatient referral for follow-up increased slightly from 73.3% in 2007−2010 to 79.7% in 2015−2018 (Ptrend = 0.02). Reflecting evidence-based guideline recommendations for headache management, opioid use substantially decreased from 2007 to 2018 among US headache-related ED visits. Future studies are warranted to identify strategies to promote evidence-based treatment for headaches (e.g., sumatriptan, dexamethasone) and appropriate outpatient referral and reduce unnecessary neuroimaging orders in EDs.
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Affiliation(s)
- Seonkyeong Yang
- Department of Pharmaceutical Outcomes & Policy, College of Pharmacy, University of Florida, Gainesville, FL 32611, USA; (S.Y.); (H.P.); (C.-Y.C.); (D.L.W.)
| | - Yulia Orlova
- Neurology Department, College of Medicine, University of Florida, Gainesville, FL 32611, USA;
| | - Abigale Lipe
- College of Pharmacy, University of Florida, Gainesville, FL 32611, USA; (A.L.); (M.B.)
| | - Macy Boren
- College of Pharmacy, University of Florida, Gainesville, FL 32611, USA; (A.L.); (M.B.)
| | - Juan M. Hincapie-Castillo
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA;
| | - Haesuk Park
- Department of Pharmaceutical Outcomes & Policy, College of Pharmacy, University of Florida, Gainesville, FL 32611, USA; (S.Y.); (H.P.); (C.-Y.C.); (D.L.W.)
- Center for Drug Evaluation and Safety, College of Pharmacy, University of Florida, Gainesville, FL 32611, USA
| | - Ching-Yuan Chang
- Department of Pharmaceutical Outcomes & Policy, College of Pharmacy, University of Florida, Gainesville, FL 32611, USA; (S.Y.); (H.P.); (C.-Y.C.); (D.L.W.)
| | - Debbie L. Wilson
- Department of Pharmaceutical Outcomes & Policy, College of Pharmacy, University of Florida, Gainesville, FL 32611, USA; (S.Y.); (H.P.); (C.-Y.C.); (D.L.W.)
| | - Lauren Adkins
- Health Science Center Libraries, University of Florida, Gainesville, FL 32611, USA;
| | - Wei-Hsuan Lo-Ciganic
- Department of Pharmaceutical Outcomes & Policy, College of Pharmacy, University of Florida, Gainesville, FL 32611, USA; (S.Y.); (H.P.); (C.-Y.C.); (D.L.W.)
- Center for Drug Evaluation and Safety, College of Pharmacy, University of Florida, Gainesville, FL 32611, USA
- Correspondence: ; Tel.: +1-352-273-6255
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Cohen F, Friedman BW. A randomized study of IV prochlorperazine plus diphenhydramine versus IV hydromorphone for migraine-associated symptoms: A post hoc analysis. Headache 2021; 61:1227-1233. [PMID: 34363617 DOI: 10.1111/head.14185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2021] [Revised: 05/18/2021] [Accepted: 05/24/2021] [Indexed: 11/30/2022]
Abstract
OBJECTIVE We conducted a randomized trial among emergency department patients with migraine to determine the relative impact on migraine-associated symptoms of hydromorphone, an opioid, versus prochlorperazine, an antidopaminergic antiemetic. METHODS This was a post hoc analysis of data from a double-blind study registered at http://clinicaltrials.gov (NCT02389829). Patients who met International Classification of Headache Disorders, 3rd edition criteria for migraine without aura or for probable migraine without aura were eligible for participation. Participants received either hydromorphone 1 mg IV or prochlorperazine 10 mg IV plus diphenhydramine 25 mg IV and could receive a second dose of the same medication 1 h later if needed. The outcomes were sustained relief of nausea, photophobia, and phonophobia. RESULTS A total of 127 patients were enrolled, of whom 63 received prochlorperazine and 64 received hydromorphone. Of 49 patients in the prochlorperazine arm who reported nausea at baseline, 34 (69.4%) reported complete resolution without relapse versus 15/49 (30.6%) in the hydromorphone arm (absolute risk reduction [ARR] = 38.8%, 95% CI: 20.5%-57.0%, p < 0.001). Of 55 patients in the prochlorperazine arm who reported photophobia at baseline, 23 (41.8%) reported complete resolution without relapse versus 13/62 (20.9%) patients treated with hydromorphone (ARR = 20.8%, 95% CI: 4.3%-37.3%, p = 0.014). Of 56 patients in the prochlorperazine arm who reported phonophobia at baseline, 25 (44.6%) reported complete resolution without relapse versus 16/59 (27.1%) in the hydromorphone arm (ARR = 17.5%, 95% CI: 0.3%-34.8%, p = 0.049). For adverse events, three patients in the prochlorperazine arm reported anxiety or restlessness, and nine patients in the hydromorphone arm reported dizziness or weakness. CONCLUSIONS Prochlorperazine plus diphenhydramine is more efficacious than hydromorphone for the treatment of migraine-associated symptoms.
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Affiliation(s)
- Fred Cohen
- Department of Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Benjamin W Friedman
- Department of Emergency Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
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Jarvis JL, Johnson B, Crowe RP. Out-of-hospital assessment and treatment of adults with atraumatic headache. J Am Coll Emerg Physicians Open 2020; 1:17-23. [PMID: 33000009 PMCID: PMC7493518 DOI: 10.1002/emp2.12006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2019] [Revised: 11/08/2019] [Accepted: 11/25/2019] [Indexed: 11/06/2022] Open
Abstract
OBJECTIVE Little is known about the presentation or management of patients with headache in the out-of-hospital setting. Our primary objective is to describe the out-of-hospital assessment and treatment of adults with benign headache. We also describe meaningful pain reduction stratified by commonly administered medications. METHODS This retrospective evaluation was conducted using data from a large national cohort. We included all 911 responses by paramedics for patients 18 and older with headache. We excluded patients with trauma, fever, suspected alcohol/drug use, or who received medications suggestive of an alternate condition. We presented our findings with descriptive statistics. RESULTS Of the 5,977,612 emergency responses, 1.1% (66,235) had a provider-documented primary impression of headache or migraine and 52.5% (34,763) met inclusion criteria. An initial pain score was recorded for 73.5% (25,544) of patients, and 58.5% (14,948) of these patients had multiple pain scores documented. Of the patients with multiple pain scores documented, 53.8% (8037) of patients had an initial pain score >5. Of these, 7.1% (573) were administered any medication. Among patients receiving a single medication, Fentanyl was the most commonly administered (32.1%, 126). As a group, opioids were the most commonly administered class of drugs (38.9%, 153) and were associated with the largest proportion of clinically significant pain reduction (69.3%, 106). Dopamine antagonists were given least frequently (9.9%, 39) but had the second largest proportion of pain reduction (43.6%, 17). CONCLUSION Out-of-hospital pain scores were documented infrequently and less than one in five patients with initial pain scores >5 received medication. Additionally, adherence to evidence-based guidelines was infrequent.
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Affiliation(s)
- Jeffrey L. Jarvis
- Williamson County EMSGeorgetownTexasUSA
- Department of Emergency MedicineBaylor Scott & White HealthcareTempleTexasUSA
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Abstract
In 2018, three calcitonin gene-related peptide (CGRP) pathway monoclonal antibodies, erenumab, fremanezumab and galcanezumab, were approved in various parts of the world, including Europe and the US, and another, eptinezumab, is pending, for the prevention of migraine. In this article, episodic migraine treatment is reviewed, although these medicines are approved and are just as effective for chronic migraine. These new medicines usher a new phase in the preventive management of migraine with migraine-specific treatments. Data from phase III trials of CGRP pathway monoclonal antibodies have shown they are efficacious, with adverse effect rates comparable to placebo. The combination of clear efficacy and excellent tolerability will be welcome in an area where poor adherence to current preventives is common. Rimegepant, ubrogepant and lasmiditan are migraine-specific acute therapies yet to be approved by regulators. Phase III data for the respective CGRP receptor antagonists, the gepants, and the serotonin 5-HT1F receptor agonist, the ditan, have been positive and free of cardiovascular adverse effects. These medicines are not vasoconstrictors. When approved, they could meet the acute therapy demand of patients with cardiovascular risk factors where triptans are contraindicated. Beyond this, gepants will see the most disruptive development in migraine management in generations with medicines that can have both acute and preventive effects, the latter evidenced by data from the discontinued drug telcagepant and the early-phase drug atogepant. Moreover, one can expect no risk of medication overuse syndromes with gepants since the more patients take, the less migraines they have. During the next years, as experience with monoclonal antibodies grows in clinical practice, we can expect an evolution in migraine management to take shape. Clinicians will be able to offer treatment patients want rather than trying to fit migraineurs into therapeutic boxes for their management. Despite pessimistic susurrations of a largely addlepated form, many patients, and physicians, will welcome new options, and the challenges of new treatment paradigms, with optimism.
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Affiliation(s)
- Calvin Chan
- Headache Group, Department of Basic and Clinical Neuroscience, Institute of Psychology, Psychiatry and Neuroscience, King's College London, London, UK.,NIHR-Wellcome Trust King's Clinical Research Facility, SLaM Biomedical Research Centre, King's College Hospital, Wellcome Foundation Building, London, SE5 9PJ, UK
| | - Peter J Goadsby
- Headache Group, Department of Basic and Clinical Neuroscience, Institute of Psychology, Psychiatry and Neuroscience, King's College London, London, UK. .,NIHR-Wellcome Trust King's Clinical Research Facility, SLaM Biomedical Research Centre, King's College Hospital, Wellcome Foundation Building, London, SE5 9PJ, UK.
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Rashed A, Mazer-Amirshahi M, Pourmand A. Current Approach to Undifferentiated Headache Management in the Emergency Department. Curr Pain Headache Rep 2019; 23:26. [PMID: 30868276 DOI: 10.1007/s11916-019-0765-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
PURPOSE OF REVIEW To discuss pharmacological interventions in the emergency department (ED) setting for the management of acute primary headache. RECENT FINDINGS Acute headache treatment in the ED has seen an expansion in terms of possible pharmacological interventions in recent years. After a thorough evaluation ruling out dangerous causes of headache, providers should take the patient's history, comorbidities, and prior therapy into consideration. Antidopaminergics have an established role in the management of acute, severe, headache with manageable side-effect profiles. However, recent studies suggest anesthetic and anti-epileptic drugs may play roles in headache treatment in the ED. Current literature also suggest steroids as a promising tool for emergency department clinicians combating the readmission of patients with recurrent headaches. Emergency medicine providers must be cognizant of these traditional and emerging therapies in order to optimize the care of headache patients.
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Affiliation(s)
- Amir Rashed
- Department of Emergency Medicine, George Washington University School of Medicine and Health Sciences, 2120 L St., Washington, DC, 20037, USA
| | - Maryann Mazer-Amirshahi
- Department of Emergency Medicine, MedStar Washington Hospital Center, Washington, DC, USA.,School of Medicine, Georgetown University, Washington, DC, USA
| | - Ali Pourmand
- Department of Emergency Medicine, George Washington University School of Medicine and Health Sciences, 2120 L St., Washington, DC, 20037, USA.
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Diener HC, Holle-Lee D, Nägel S, Dresler T, Gaul C, Göbel H, Heinze-Kuhn K, Jürgens T, Kropp P, Meyer B, May A, Schulte L, Solbach K, Straube A, Kamm K, Förderreuther S, Gantenbein A, Petersen J, Sandor P, Lampl C. Treatment of migraine attacks and prevention of migraine: Guidelines by the German Migraine and Headache Society and the German Society of Neurology. CLINICAL AND TRANSLATIONAL NEUROSCIENCE 2019. [DOI: 10.1177/2514183x18823377] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
In collaboration with some of the leading headache centres in Germany, Switzerland and Austria, we have established new guidelines for the treatment of migraine attacks and the prevention of migraine. A thorough literature research of the last 10 years has been the basis of the current recommendations. At the beginning, we present therapeutic novelties, followed by a summary of all recommendations. After an introduction, we cover topics like drug therapy and practical experience, non-effective medication, migraine prevention, interventional methods, non-medicational and psychological methods for prevention and therapies without proof of efficacy.
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Affiliation(s)
- Hans-Christoph Diener
- Klinik für Neurologie und Westdeutsches Kopfschmerzzentrum, Universitätsklinikum Essen, Essen, Germany
| | - Dagny Holle-Lee
- Klinik für Neurologie und Westdeutsches Kopfschmerzzentrum, Universitätsklinikum Essen, Essen, Germany
| | - Steffen Nägel
- Klinik für Neurologie und Westdeutsches Kopfschmerzzentrum, Universitätsklinikum Essen, Essen, Germany
| | - Thomas Dresler
- Klinik für Psychiatrie und Psychotherapie, Universität Tübingen, Tübingen, Germany
- Graduiertenschule & Forschungsnetzwerk LEAD, Universität Tübingen, Tübingen, Germany
| | - Charly Gaul
- Migräne- und Kopfschmerzklinik Königstein, Königstein im Taunus, Germany
| | | | | | - Tim Jürgens
- Universitätsmedizin Rostock, Zentrum für Nervenheilkunde, Klinik und Poliklinik für Neurologie, Rostock, Germany
| | - Peter Kropp
- Institut für Medizinische Psychologie und Medizinische Soziologie, Universitätsmedizin Rostock, Zentrum für Nervenheilkunde, Rostock, Germany
| | - Bianca Meyer
- Institut für Medizinische Psychologie und Medizinische Soziologie, Universitätsmedizin Rostock, Zentrum für Nervenheilkunde, Rostock, Germany
| | - Arne May
- Institut für Systemische Neurowissenschaften, Universitätsklinikum Hamburg Eppendorf (UKE), Hamburg, Germany
| | - Laura Schulte
- Institut für Systemische Neurowissenschaften, Universitätsklinikum Hamburg Eppendorf (UKE), Hamburg, Germany
| | - Kasja Solbach
- Klinik für Neurologie, Universitätsklinikum Essen, Essen, Germany
| | - Andreas Straube
- Neurologische Klinik, Ludwig-Maximilians-Universität München, Klinikum Großhadern, München, Germany
| | - Katharina Kamm
- Neurologische Klinik, Ludwig-Maximilians-Universität München, Klinikum Großhadern, München, Germany
| | - Stephanie Förderreuther
- Neurologische Klinik, Ludwig-Maximilians-Universität München, Klinikum Großhadern, München, Germany
| | | | - Jens Petersen
- Klinik für Neurologie, Universitätsspital Zürich, Zürich, Swizterland
| | - Peter Sandor
- RehaClinic Bad Zurzach, Bad Zurzach, Swizterland
| | - Christian Lampl
- Ordensklinikum Linz, Krankenhaus der Barmherzigen Schwestern Linz Betriebsgesellschaft m.b.H., Linz, Austria
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Abstract
The Research to Practice Column is designed to improve translational research critique skills of nurse practitioners (NPs). In this issue, the article "Randomized study of IV prochlorperazine plus diphenhydramine vs IV hydromorphone for migraine" is discussed in the context of a patient with an acute headache presenting to the emergency department (ED). The study was designed to assess the efficacy of intravenous prochlorperazine and diphenhydramine as compared with intravenous hydromorphone for patients with acute migraine in the ED. With the growing trend to avoid the use of opiates to curb potential addiction and increased ED length of stay, NPs need to be aware of efficacious, evidence-based treatments for acute migraines, a common ED presentation.
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Ruzek M, Richman P, Eskin B, Allegra JR. ED treatment of migraine patients has changed. Am J Emerg Med 2018; 37:1069-1072. [PMID: 30170929 DOI: 10.1016/j.ajem.2018.08.051] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2018] [Revised: 07/29/2018] [Accepted: 08/20/2018] [Indexed: 02/02/2023] Open
Abstract
STUDY OBJECTIVES Numerous studies have shown benefits of nonnarcotic treatments for emergency department (ED) migraine patients. Our goal was to determine if ED treatment of migraine patients and the rate of return within 72 h have changed. METHODS Design: Multi-hospital retrospective cohort. POPULATION Consecutive ED patients from 1-1-1999 to 9-31-2014. PROTOCOL For determining treatments, we examined charts at the beginning (1999-2000) and end (2014) of the time period. We combined similar medications into the following groups: parenteral narcotics, oral narcotics, antihistamines and dopamine receptor antagonists prochlorperazine/metoclopramide (DRA). We calculated the percent of migraine patients given each treatment in each time period. We identified those who returned to the same ED within 72 h, and calculated the difference in annual return rates between 1999-2000 and 2014. RESULTS Of the 2,824,710 total visits, 8046 (0.28%) were for migraine. We reviewed 290 charts (147 in 1999-2000 and 143 in 2014) to determine migraine treatments. The use of IV fluids, DRA, ketorolac and dexamethasone increased from 1999-2000 to 2014, whereas narcotic use and discharge prescriptions for narcotics decreased. Of the 8046 migraine patients, 624 (8%) returned within 72 h. The return rate decreased from 1999-2000 to 2014 from 12% to 4% (difference = 8%, 95% CI 5%-11%). CONCLUSION For ED migraine patients, the use of IV fluids, DRA, ketorolac and dexamethasone increased whereas the use of narcotics and discharge prescriptions for narcotics decreased. The return rates for migraines decreased. We speculate that the increased use of non-narcotic medications contributed to this decrease.
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Affiliation(s)
- Michael Ruzek
- Morristown Medical Center, Morristown, NJ, United States of America
| | - Peter Richman
- Christus Spohn/Texas A&M School of Medicine, Corpus Christi, TX, United States of America
| | - Barnet Eskin
- Morristown Medical Center, Morristown, NJ, United States of America
| | - John R Allegra
- Morristown Medical Center, Morristown, NJ, United States of America.
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Dodson H, Bhula J, Eriksson S, Nguyen K. Migraine Treatment in the Emergency Department: Alternatives to Opioids and their Effectiveness in Relieving Migraines and Reducing Treatment Times. Cureus 2018; 10:e2439. [PMID: 29881652 PMCID: PMC5990028 DOI: 10.7759/cureus.2439] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
The objective of this literature review is to evaluate the efficacy of opioids for the treatment of headaches, particularly migraines, in the emergency department (ED). Despite safer alternatives, opiates are routinely used as an abortive treatment for migraine headaches. The studies reviewed demonstrate that opiates are less effective in terminating acute headaches and result in prolonged ED visits. Dopamine receptor antagonists, such as metoclopramide and prochlorperazine, were the most efficacious in terminating migraines in the studies examined.
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Affiliation(s)
- Haley Dodson
- College of Medicine, University of Central Florida, Orlando, USA
| | - Jay Bhula
- College of Medicine, University of Central Florida, Orlando, USA
| | - Sven Eriksson
- College of Medicine, University of Central Florida, Orlando, USA
| | - Khoa Nguyen
- College of Medicine, University of Central Florida, Orlando, USA
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11
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Friedman BW, Irizarry E, Solorzano C, Latev A, Rosa K, Zias E, Vinson DR, Bijur PE, Gallagher EJ. Randomized study of IV prochlorperazine plus diphenhydramine vs IV hydromorphone for migraine. Neurology 2017; 89:2075-2082. [PMID: 29046364 DOI: 10.1212/wnl.0000000000004642] [Citation(s) in RCA: 49] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2017] [Accepted: 08/30/2017] [Indexed: 01/03/2023] Open
Abstract
OBJECTIVE To determine outcomes among patients with migraine in the emergency department (ED) who receive IV hydromorphone vs IV prochlorperazine + diphenhydramine. METHODS This study was conducted in 2 EDs in New York City. Patients who met international criteria for migraine were eligible for participation if they had not used an opioid within the previous month. Clinicians, participants, investigators, and research personnel were blinded to treatment. Patients were randomized in blocks of 4. Participants received hydromorphone 1 mg or prochlorperazine 10 mg + diphenhydramine 25 mg. Diphenhydramine was administered to prevent akathisia, a common side effect of IV prochlorperazine. The primary outcome was sustained headache relief, defined as achieving a headache level of mild or none within 2 hours of medication administration and maintaining that level for 48 hours without the requirement of rescue medication. A planned interim analysis was conducted once 48-hour data were available for 120 patients. RESULTS The trial was halted by the data monitoring committee after 127 patients had been enrolled. The primary outcome was achieved in the prochlorperazine arm by 37 of 62 (60%) participants and in the hydromorphone arm by 20 of 64 (31%) participants (difference 28%, 95% confidence interval 12-45, number needed to treat 4, 95% confidence interval 2-9). CONCLUSIONS IV hydromorphone is substantially less effective than IV prochlorperazine for the treatment of acute migraine in the ED and should not be used as first-line therapy. CLINICALTRIALSGOV IDENTIFIER NCT02389829. CLASSIFICATION OF EVIDENCE This study provides Class I evidence that for patients in the ED with migraine, IV prochlorperazine + diphenhydramine is superior to IV hydromorphone.
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Affiliation(s)
- Benjamin W Friedman
- From the Department of Emergency Medicine (B.W.F., E.I., A.L., K.R., P.E.B., E.J.G.), Albert Einstein College of Medicine, and Department of Pharmacy (C.S., E.Z.), Montefiore Health System, Bronx, NY; Permanente Medical Group and the Kaiser Permanente Division of Research (D.R.V.), Oakland; and Kaiser Permanente Sacramento Medical Center (D.R.V.), CA.
| | - Eddie Irizarry
- From the Department of Emergency Medicine (B.W.F., E.I., A.L., K.R., P.E.B., E.J.G.), Albert Einstein College of Medicine, and Department of Pharmacy (C.S., E.Z.), Montefiore Health System, Bronx, NY; Permanente Medical Group and the Kaiser Permanente Division of Research (D.R.V.), Oakland; and Kaiser Permanente Sacramento Medical Center (D.R.V.), CA
| | - Clemencia Solorzano
- From the Department of Emergency Medicine (B.W.F., E.I., A.L., K.R., P.E.B., E.J.G.), Albert Einstein College of Medicine, and Department of Pharmacy (C.S., E.Z.), Montefiore Health System, Bronx, NY; Permanente Medical Group and the Kaiser Permanente Division of Research (D.R.V.), Oakland; and Kaiser Permanente Sacramento Medical Center (D.R.V.), CA
| | - Alexander Latev
- From the Department of Emergency Medicine (B.W.F., E.I., A.L., K.R., P.E.B., E.J.G.), Albert Einstein College of Medicine, and Department of Pharmacy (C.S., E.Z.), Montefiore Health System, Bronx, NY; Permanente Medical Group and the Kaiser Permanente Division of Research (D.R.V.), Oakland; and Kaiser Permanente Sacramento Medical Center (D.R.V.), CA
| | - Karolyn Rosa
- From the Department of Emergency Medicine (B.W.F., E.I., A.L., K.R., P.E.B., E.J.G.), Albert Einstein College of Medicine, and Department of Pharmacy (C.S., E.Z.), Montefiore Health System, Bronx, NY; Permanente Medical Group and the Kaiser Permanente Division of Research (D.R.V.), Oakland; and Kaiser Permanente Sacramento Medical Center (D.R.V.), CA
| | - Eleftheria Zias
- From the Department of Emergency Medicine (B.W.F., E.I., A.L., K.R., P.E.B., E.J.G.), Albert Einstein College of Medicine, and Department of Pharmacy (C.S., E.Z.), Montefiore Health System, Bronx, NY; Permanente Medical Group and the Kaiser Permanente Division of Research (D.R.V.), Oakland; and Kaiser Permanente Sacramento Medical Center (D.R.V.), CA
| | - David R Vinson
- From the Department of Emergency Medicine (B.W.F., E.I., A.L., K.R., P.E.B., E.J.G.), Albert Einstein College of Medicine, and Department of Pharmacy (C.S., E.Z.), Montefiore Health System, Bronx, NY; Permanente Medical Group and the Kaiser Permanente Division of Research (D.R.V.), Oakland; and Kaiser Permanente Sacramento Medical Center (D.R.V.), CA
| | - Polly E Bijur
- From the Department of Emergency Medicine (B.W.F., E.I., A.L., K.R., P.E.B., E.J.G.), Albert Einstein College of Medicine, and Department of Pharmacy (C.S., E.Z.), Montefiore Health System, Bronx, NY; Permanente Medical Group and the Kaiser Permanente Division of Research (D.R.V.), Oakland; and Kaiser Permanente Sacramento Medical Center (D.R.V.), CA
| | - E John Gallagher
- From the Department of Emergency Medicine (B.W.F., E.I., A.L., K.R., P.E.B., E.J.G.), Albert Einstein College of Medicine, and Department of Pharmacy (C.S., E.Z.), Montefiore Health System, Bronx, NY; Permanente Medical Group and the Kaiser Permanente Division of Research (D.R.V.), Oakland; and Kaiser Permanente Sacramento Medical Center (D.R.V.), CA
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Najjar M, Hall T, Estupinan B. Metoclopramide for Acute Migraine Treatment in the Emergency Department: An Effective Alternative to Opioids. Cureus 2017; 9:e1181. [PMID: 28533997 PMCID: PMC5438233 DOI: 10.7759/cureus.1181] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
In light of recent warnings by the United States (US) Surgeon General and Centers for Disease Control (CDC) guidelines for recommending more prudent use of opioid narcotics, the search for a non-opioid alternative for aborting acute migraines is particularly relevant. The CDC also estimates the prevalence of opioid dependence may be as high as 26% among patients prescribed opioids for chronic pain, not due to cancer, in the primary care setting. Given such staggering data, it is imperative that we, as caretakers, not foster opioid dependence but rather continue to investigate non-opioid therapies for the management of acute migraines in the emergent care settings. Our literature review demonstrates that metoclopramide should be used more frequently as first-line therapy for an acute migraine over opioids. The use of opioids specifically has been discouraged as migraine treatment by the American Headache Society citing “insufficient evidence” as the main reason. Metoclopramide, specifically using the 10 mg dose, has been cited as “highly likely to be effective” by the same guidelines. Another major issue with opioids is the growing potential for abuse, thus minimizing the use of these drugs for only special circumstances would be beneficial overall.
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Affiliation(s)
- Mejdi Najjar
- College of Medicine, University of Central Florida College of Medicine
| | - Tyler Hall
- College of Medicine, University of Central Florida College of Medicine
| | - Blanca Estupinan
- College of Medicine, University of Central Florida College of Medicine
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McCarthy LH, Cowan RP. Comparison of parenteral treatments of acute primary headache in a large academic emergency department cohort. Cephalalgia 2015; 35:807-15. [PMID: 25366551 PMCID: PMC4417651 DOI: 10.1177/0333102414557703] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2014] [Accepted: 09/08/2014] [Indexed: 12/23/2022]
Abstract
OBJECTIVE The objective of this article is to compare acute primary headache patient outcomes in those initially treated with parenteral opiates or non-opiate recommended headache medications in a large academic medical emergency department (ED). BACKGROUND Many acute primary headache patients are not diagnosed with a specific headache type and are treated with opiates and nonspecific pain medications in the ED setting. This is inconsistent with multiple expert recommendations. METHODS Electronic charts were reviewed from 574 consecutive patients who visited the ED for acute primary headache (identified by chief complaint and ICD9 codes) and were treated with parenteral medications. RESULTS Non-opiate recommended headache medications were given first line to 52.6% and opiates to 22.8% of all participants. Patients given opiates first had significantly longer length of stays (median 5.0 vs. 3.9 hours, p < 0.001) and higher rates of return ED visits within seven days (7.6% vs. 3.0%, p = 0.033) compared with those given non-opiate recommended medications in univariate analysis. Only the association with longer length of stay remained significant in multivariable regression including possible confounding variables. CONCLUSIONS Initial opiate use is associated with longer length of stay compared with non-opiate first-line recommended medications for acute primary headache in the ED. This association remained strong and significant even after multivariable adjustment for headache diagnosis and other possible confounders.
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Affiliation(s)
- Lucas H McCarthy
- Stanford University, Department of Neurology, USA Puget Sound VA Healthcare System, USA
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Friedman BW, West J, Vinson DR, Minen MT, Restivo A, Gallagher EJ. Current management of migraine in US emergency departments: An analysis of the National Hospital Ambulatory Medical Care Survey. Cephalalgia 2014; 35:301-9. [DOI: 10.1177/0333102414539055] [Citation(s) in RCA: 67] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Background Published data from 1998 revealed that most patients treated for migraine in an emergency department received opioids. Over the intervening years, a large body of evidence has emerged demonstrating the efficacy and safety of non-opioid alternatives. Expert opinion during these years has cautioned against use of opioids for migraine. Our objectives were to compare current frequency of use of various medications for acute migraine in US emergency departments with use of these same medications in 1998 and to identify factors independently associated with opioid use. Methods We analyzed National Hospital Ambulatory Medical Care Survey data from 2010, the most current dataset available. The National Hospital Ambulatory Medical Care Survey is a public dataset collected and distributed by the Centers for Disease Control and Prevention. It is a multi-stage probability sample from randomly selected emergency departments across the country, designed to be representative of all US emergency department visits. We included in our analysis all patients with the ICD9 emergency department discharge diagnosis of migraine. We tabulated frequency of use of specific medications in 2010 and compared these results with the 1998 data. Using a logistic regression model, into which all of the following variables were entered, we explored the independent association between any opioid use in 2010 and sex, age, race/ethnicity, geographic region, type of hospital, triage pain score and history of emergency department use within the previous 12 months. Results In 2010, there were 1.2 (95% confidence interval 0.9, 1.4) million migraine visits to US emergency departments. Including opioid-containing oral analgesic combinations, opioids were administered in 59% of visits (95% confidence interval 51, 67). The most commonly used parenteral agent, hydromorphone, was used in 25% (95% confidence interval 19, 33) of visits in 2010 versus less than 1% (95% confidence interval 0, 3) in 1998. Conversely, use of meperidine had decreased markedly over the same timeframe. In 2010, it was used in just 7% (95% confidence interval 4, 12) of visits compared to 37% (95% confidence interval 29, 45) in 1998. Metoclopramide, the most commonly used anti-dopaminergic, was administered in 17% (95% confidence interval 12, 23) of visits in 2010 and 3% (95% confidence interval 1, 6) of visits in 1998. Use of any triptan was relatively uncommon in 2010 (7% (95% confidence interval 4, 11) of visits) and in 1998 (10% (95% confidence interval 6, 15) of visits). Of the predictor variables listed above, only emergency department use within the previous 12 months was associated with opioid administration (adjusted odds ratio: 2.87 (95% confidence interval 1.03, 7.97)). Conclusions In spite of recommendations to the contrary, opioids are still used in more than half of all emergency department visits for migraine. Though use of meperidine has decreased markedly between 1998 and 2010, it has largely been replaced by hydromorphone. Opioid use in migraine visits is independently associated with prior visits to the same emergency department in the previous 12 months.
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Affiliation(s)
- Benjamin W Friedman
- Department of Emergency Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, NY, USA
| | - Jason West
- Department of Emergency Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, NY, USA
| | - David R Vinson
- Department of Emergency Medicine, Kaiser Permanente Sacramento Medical Center, CA, USA
| | - Mia T Minen
- John Graham Headache Center, Department of Neurology, Brigham and Women’s Faulkner Hospital and Harvard Medical School, MA, USA
| | - Andrew Restivo
- Department of Emergency Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, NY, USA
| | - E John Gallagher
- Department of Emergency Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, NY, USA
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Chest Pain A Manifestation of Migraine. J Emerg Med 2014; 46:420-7. [DOI: 10.1016/j.jemermed.2013.08.019] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2013] [Revised: 06/26/2013] [Accepted: 08/08/2013] [Indexed: 01/05/2023]
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Abstract
Headache is the fifth most common primary complaint of patients presenting to an emergency department (ED) in the United States. The emergency physician (EP) plays a unique role in the management of these patients, one that differs from that of the primary care physician, the neurologist, and other specialists. Diagnostic nomenclature used in the ED is necessarily less specific, as care is more appropriately focused on the relief of symptoms and the identification of life-threatening causes. By seeking a limited number of specific critical features on history and physical examination, the EP can minimize the risk of overlooking one of these dangerous causes of headache. When certain features are present, empirical therapies and diagnostic testing should be initiated in the ED. The most frequently encountered pitfalls in the management of patients with headache in emergency medicine practice, and those with the greatest likelihood to adversely affect patient outcomes, are discussed.
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