Treatment of migraine with intramuscular chlorpromazine

The effectiveness of parenteral agents for pain reduction in patients with migraine presenting to emergency settings: A systematic review and network analysis

OBJECTIVES

To assess the comparative effectiveness and safety of parenteral agents for pain reduction in patients with acute migraine.

BACKGROUND

Parenteral agents have been shown to be effective in treating acute migraine pain; however, the comparative effectiveness of different approaches is unclear.

METHODS

Nine electronic databases and gray literature sources were searched to identify randomized clinical trials assessing parenteral agents to treat acute migraine pain in emergency settings. Two independent reviewers completed study screening, data extraction, and Cochrane risk-of-bias assessment, with differences being resolved by adjudication. The protocol of the review was registered with the International Prospective Register of Systematic Reviews (PROSPERO; CRD42018100096).

RESULTS

A total of 97 unique studies were included, with most studies reporting a high or unclear risk of bias. Monotherapy, as well as combination therapy, successfully reduced pain scores prior to discharge. They also increased the proportion of patients reporting pain relief and being pain free. Across the pain outcomes assessed, combination therapy was one of the higher ranked approaches and provided robust improvements in pain outcomes, including lowering pain scores (mean difference -3.36, 95% confidence interval [CI] -4.64 to -2.08) and increasing the proportion of patients reporting pain relief (risk ratio [RR] 2.83, 95% CI 1.74-4.61). Neuroleptics and metoclopramide also ranked high in terms of the proportion of patients reporting pain relief (neuroleptics RR 2.76, 95% CI 2.12-3.60; metoclopramide RR 2.58, 95% CI 1.90-3.49) and being pain free before emergency department discharge (neuroleptics RR 4.8, 95% CI 3.61-6.49; metoclopramide RR 4.1, 95% CI 3.02-5.44). Most parenteral agents were associated with increased adverse events, particularly combination therapy and neuroleptics.

CONCLUSIONS

Various parenteral agents were found to provide effective pain relief. Considering the consistent improvements across various outcomes, combination therapy, as well as monotherapy of either metoclopramide or neuroleptics are recommended as first-line options for managing acute migraine pain. There are risks of adverse events, especially akathisia, following treatment with these agents. We recommend that a shared decision-making model be considered to effectively identify the best treatment option based on the patient's needs.

Acute Treatments for Episodic Migraine in Adults: A Systematic Review and Meta-analysis

IMPORTANCE

Migraine is common and can be associated with significant morbidity, and several treatment options exist for acute therapy.

OBJECTIVE

To evaluate the benefits and harms associated with acute treatments for episodic migraine in adults.

DATA SOURCES

Multiple databases from database inception to February 24, 2021.

STUDY SELECTION

Randomized clinical trials and systematic reviews that assessed effectiveness or harms of acute therapy for migraine attacks.

DATA EXTRACTION AND SYNTHESIS

Independent reviewers selected studies and extracted data. Meta-analysis was performed with the DerSimonian-Laird random-effects model with Hartung-Knapp-Sidik-Jonkman variance correction or by using a fixed-effect model based on the Mantel-Haenszel method if the number of studies was small.

MAIN OUTCOMES AND MEASURES

The main outcomes included pain freedom, pain relief, sustained pain freedom, sustained pain relief, and adverse events. The strength of evidence (SOE) was graded with the Agency for Healthcare Research and Quality Methods Guide for Effectiveness and Comparative Effectiveness Reviews.

FINDINGS

Evidence on triptans and nonsteroidal anti-inflammatory drugs was summarized from 15 systematic reviews. For other interventions, 115 randomized clinical trials with 28 803 patients were included. Compared with placebo, triptans and nonsteroidal anti-inflammatory drugs used individually were significantly associated with reduced pain at 2 hours and 1 day (moderate to high SOE) and increased risk of mild and transient adverse events. Compared with placebo, calcitonin gene-related peptide receptor antagonists (low to high SOE), lasmiditan (5-HT1F receptor agonist; high SOE), dihydroergotamine (moderate to high SOE), ergotamine plus caffeine (moderate SOE), acetaminophen (moderate SOE), antiemetics (low SOE), butorphanol (low SOE), and tramadol in combination with acetaminophen (low SOE) were significantly associated with pain reduction and increase in mild adverse events. The findings for opioids were based on low or insufficient SOE. Several nonpharmacologic treatments were significantly associated with improved pain, including remote electrical neuromodulation (moderate SOE), transcranial magnetic stimulation (low SOE), external trigeminal nerve stimulation (low SOE), and noninvasive vagus nerve stimulation (moderate SOE). No significant difference in adverse events was found between nonpharmacologic treatments and sham.

CONCLUSIONS AND RELEVANCE

There are several acute treatments for migraine, with varying strength of supporting evidence. Use of triptans, nonsteroidal anti-inflammatory drugs, acetaminophen, dihydroergotamine, calcitonin gene-related peptide antagonists, lasmiditan, and some nonpharmacologic treatments was associated with improved pain and function. The evidence for many other interventions, including opioids, was limited.

Dopamine and Migraine: Biology and Clinical Implications

In the last 30 years dopamine has been considered as playing a role in the pathogenesis of migraine. The literature indicates that migraineurs are hypersensitive to dopamine agonists with respect to some of the premonitory symptoms of migraine such as nausea and yawning. There are various nonspecific dopamine D2 receptor antagonists that show good clinical efficacy in migraine, and also a number of polymorphisms of dopaminergic genes related to migraine. Animal studies have also shown that dopamine receptors are present in the trigeminovascular system, the area believed to be involved in headache pain, and neuronal firing here is reduced by dopamine agonists. There appears to be little effect of dopamine on peripheral trigeminal afferents. We assess some of the limitations of the clinical studies with regard to the therapeutics, and those found in the studies that discovered differences in genetic polymorphisms in migraine, and consider the implications of this on a dopaminergic hypothesis of migraine.

Management of Pediatric Migraine Headache in the Emergency Room and Infusion Center

Migraine is a common disorder that starts at an early age and takes a variable pattern from intermittent to chronic headache with several exacerbations throughout a lifetime. Children and adolescents are significantly affected. If an acute headache is not aborted by outpatient migraine therapy, it often causes severe disability, preventing the child from attending school and social events. Treating the acute severe headache aggressively helps prevent prolonged disability as well as possible chronification. Multiple medications are available, mostly for the outpatient management of an attack and include the use of over-the-counter anti-inflammatory medications as well as prescribed medications in the triptan group. These therapies do sometime fail and the exacerbation can last from days to weeks. If the headache lasts 72 hours or longer it will fall in the category of status migrainosus. Status migrainosus is described as a severe disabling headache lasting 72 hours or more by the ICHD3 criteria. Disability is a major issue in children and adolescents and aggressive acute measures are to be taken to control it as soon as possible. Early aggressive intravenous therapy can be very effective in breaking the attack and allowing the child to be quickly back to normal functioning. This article reviews what is available for the treatment of pediatric primary headaches in the emergency room.

Pharmacological Acute Migraine Treatment Strategies: Choosing the Right Drug for a Specific Patient

Background:

In our targeted review (Section 2), 12 acute medications received a strong recommendation for use in acute migraine therapy while four received a weak recommendation for use. Strong recommendations were made to avoid use of two other medications, except for exceptional circumstances. Two anti-emetics received strong recommendations for use as needed.

Objective:

To organize the available acute migraine medications into acute migraine treatment strategies in order to assist the practitioner in choosing a specific medication(s) for an individual patient.

Methods:

Acute migraine treatment strategies were developed based on the targeted literature review used for the development of this guideline (Section 2), and a general literature review. Expert consensus groups were used to refine and validate these strategies.

Results:

Based on evidence for drug efficacy, drug side effects, migraine severity, and coexistent medical disorders, our analysis resulted in the formulation of eight general acute migraine treatment strategies. These could be grouped into four categories: 1) two mild-moderate attack strategies, 2) two moderate-severe attack or NSAID failure strategies, 3) three refractory migraine strategies, and 4) a vasoconstrictor unresponsive-contraindicated strategy. In addition, strategies were developed for menstrual migraine, migraine during pregnancy, and migraine during lactation. The eight general treatment strategies were coordinated with a “combined acute medication approach” to therapy which used features of both the “stratified” and the “step care across attacks” approaches to acute migraine management.

Conclusions:

The available medications for acute migraine treatment can be organized into a series of strategies based on patient clinical features. These strategies may help practitioners make appropriate acute medication choices for patients with migraine.

Treatment of pediatric migraine in the emergency room

Migraine constitutes a relatively common reason for pediatric emergency room visits. Given the paucity of randomized trials involving pediatric migraineurs in the emergency department setting compared with adults, recommendations for managing these children are largely extrapolated from adult migraine emergency room studies and trials involving outpatient home pediatric migraine therapy. We review current knowledge about pediatric migraineurs presenting at the emergency room and their management, and summarize the best evidence available to guide clinical decision-making.

Rescue therapy for acute migraine, part 2: neuroleptics, antihistamines, and others

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.

A Neurologist's Guide to Acute Migraine Therapy in the Emergency Room

Migraine is a common reason for visits to the emergency room. Attacks that lead patients to come to the emergency room are often more severe, refractory to home rescue medication, and have been going on for longer. All of these features make these attacks more challenging to treat. The purpose of this article is to review available evidence pertinent to the treatment of acute migraine in adults in the emergency department setting in order to provide neurologists with a rational approach to management. Drug classes and agents reviewed include opioids, dopamine receptor antagonists, triptans, nonsteroidal anti-inflammatory drugs, corticosteroids, and sodium valproate.

Neuroleptics in Headache

OBJECTIVES

To review the mechanism of action of neuroleptics, the evidence for their efficacy, and their clinical use in headache treatment.

BACKGROUND

Neuroleptics and antiemetics have long been used for headache treatment; however, they have not been widely utilized because of general unfamiliarity with them and concerns about their adverse events. With the recent advent of the atypical neuroleptics and their improved adverse event profile, our armamentarium for headache treatment has expanded. In this review, we explore the mechanism of action of these classes of drugs, their adverse events, and the evidence for their efficacy. We also detail our experience with the different drugs and how we use them as both acute and preventive headache therapy.

DESIGN

A review of published literature was obtained through a MEDLINE search on the use of neuroleptics in headache therapy.

CONCLUSION

Neuroleptics have widespread evidence supporting their use in headache treatment and present an important part of the armaterium against headache.

Treatment of primary headache in the emergency department

BACKGROUND

Each year many patients present to an emergency department for treatment of acute primary headache. We investigated the diagnosis and clinical outcome of patients treated for primary headache in the emergency department.

METHODS

Patients treated for acute primary headache in the emergency department completed a questionnaire related to their headache symptoms, response to treatment, and ability to return to normal function. These responses were compared to the treating physicians' observations of the patient's condition at the time of discharge from the emergency department.

RESULTS

Based on the questionnaire, 95% of the 57 respondents met International Headache Society diagnostic criteria for migraine. Emergency department physicians, however, diagnosed only 32% of the respondents with migraine, while 59% were diagnosed as having "cephalgia" or "headache NOS" (not otherwise specified). All patients previously had taken nonprescription medication, and 49% had never taken a triptan. In the emergency department, only 7% of the patients received a drug "specific" for migraine (ie, a triptan or dihydroergotamine). Sixty-five percent of the patients were treated with a "migraine cocktail" comprised of a variable mixture of a nonsteroidal anti-inflammatory agent, a dopamine antagonist, and/or an antihistamine; 24% were treated with opioids. All 57 patients reported that after discharge they had to rest or sleep and were unable to return to normal function. Sixty percent of patients still had headache 24 hours after discharge from the emergency department.

CONCLUSION

The overwhelming majority of patients who present to an emergency department with acute primary headache have migraine, but the majority of patients receive a less specific diagnosis and a treatment that is correspondingly nonspecific.

Therapeutic implications of the modular headache theory

A theoretical approach to understanding the primary headaches not yet classified by the International Headache Society classification system has been developed by the authors. It is proposed that groups of neurons, called modules, become activated to produce each symptom of a primary headache disorder and these modules are linked together to produce a headache. Headaches develop phenotypic stability through the process of learned stereotypy. This theory explains the huge diversity of headache phenomenology. It has implications for the classification, research and treatment of headache patients. The modular headache theory has therapeutic implications by directing us to focus on treatable modules and avoiding unnecessary treatment for less treatable symptoms. This allows for rational approaches to CNS hyperexcitability and incorporates the temporal patterns of modular activation into the patient's treatment plan.

Efficacy and tolerability of prochlorperazine buccal tablets in treatment of acute migraine

OBJECTIVES

To study the efficacy and tolerability of prochlorperazine (PCZ) management of acute migraine.

DESIGN AND METHODS

A double blind comparative study was conducted to assess the efficacy of buccal PCZ 3 mg compared with oral ergotamine tartarate 1 mg plus caffeine 100 mg (ERG) or placebo (buccal or oral) for treatment of acute migraine. In all, 114 episodes of acute migraine were evaluated. Patients graded symptoms on a four-point scale before and up to 4 hours after treatment. The primary efficacy parameters included headache resolution within 2 hours (grade 3 or 2 to grade 0) and alleviation of other accompanying symptoms of migraine. The supplementary endpoints included improvement in quality of life (QOL).

RESULTS

The percentage of patients reporting resolution of headache (to grade 0) was 51.4% for buccal PCZ and 21.7% for buccal placebo, 23.1% for oral ERG and 28.6% for oral placebo, headache tended to recur in both the placebo and ERG groups after initial improvement. Buccal PCZ was well tolerated; no signs of local irritation were evident, and patients found the formulation easy to use. Mild but transient sedation and drowsiness were observed in 41%.

CONCLUSIONS

In the present study, PCZ 3 mg via the buccal route produced faster improvement and greater efficacy than placebo (oral as well as buccal) or oral ERG. The global QOL score 2 hours after treatment scores was higher in the PCZ group. Buccal PCZ may represent a particularly effective alternative for acute migraine treatment.

Emergency Room Treatment of Migraine Headache

Headache is the chief complaint in the emergency room in between 0.36% and 2.5% of patients. It is essential that the headache diagnosis be established to rule-out a potentially morbid disorder, as well as facilitate selection of appropriate interventions. Referral with follow-up care is essential to patients with frequent headaches in order to prevent repeat emergency room visits and possible narcotic dependency. Two stages define emergency room treatment of any form of headache--initial stabilization and treatment (which may be started in the emergency room). Despite the introduction of migraine-specific therapy in 1993, only a minority of migraine headache patients are prescribed this treatment.

Intravenous chlorpromazine in the acute treatment of episodic tension-type headache: a randomized, placebo controlled, double-blind study

Acute headache is a very frequent symptom, responsible for a significant percentage of caseload at primary care units and emergency rooms. Chlorpromazine is easily available in such settings. The aim of this study is to conduct a randomized, placebo-controlled, double-blind study to assess the efficacy of chlorpromazine on the acute treatment of episodic tension-type headache. We randomized 30 patients to receive placebo (10 ml of saline intravenous injections) and 30 patients to receive 0.1 mg/Kg chlorpromazine intravenously. We used 7 parameters of analgesic evaluation. Patients receiving chlorpromazine showed a statistically significant improvement (p < 0.05 and p < 0.01) of pain compared to placebo, far up to 30 minutes after the drug administration. The therapeutic gain was 36.7% in 30 minutes and 56.6 % in 60 minutes. The number needed to treat (NNT, the reciprocal or the therapeutic gain) was 2.7 in 30 minutes and 1.8 in 60 minutes. There were reductions in the recurrence and in the use of rescue medication in the chlorpromazine group. We can conclude that intravenous chlorpromazine is an effective drug to relief the pain in tension-type headache.

Intravenous chlorpromazine in the emergency department treatment of migraines: a randomized controlled trial

The aim of this study is to assess, in a double blind randomized clinical trial, the effect of chlorpromazine (CPZ) on the pain and associated symptoms in patients with migraine. Sixty patients with migraine with aura and 68 patients with migraine without aura were assigned at random to receive IV 0.1 mg/Kg CPZ or placebo. We assessed pain intensity, nausea, photophobia, and phonophobia at baseline, 30 min, and 60 min post-IV administration. End-point efficacy at 60 min was used to calculate the number needed to treat (NNT). We also recorded adverse effects, need for rescue medication at 24 h, and recurrence of headache at 24 h. We found clinically and statistically significant (p < 0.01) improvement associated with CPZ in pain scores, nausea, photophobia, phonophobia, and need for rescue medication, all at 60 min, and in rate of recurrence at 24 h, both in patients with and without aura. NNT = 2. Those allocated to CPZ had less nausea and dyspepsia, but more drowsiness and postural hypotension than those receiving placebo. CPZ is an excellent option for the treatment of migraines, with and without aura, in the Emergency Department.

Headache in the emergency department

OBJECTIVE

To perform an observational study of the demographics, clinical factors, and therapeutic efficacy in patients presenting to the emergency department with a chief complaint of headache.

BACKGROUND

Acute headache presentations to the emergency department are a therapeutic dilemma for physicians.

METHODS

Patients presenting with nontraumatic headache to the emergency department of Hermann Hospital in Houston, Texas, during a 16-month period were prospectively ascertained by active and passive surveillance. The medical record was abstracted. Demographic and clinical information are presented with descriptive statistics. Relative benefit of individual therapies are compared with odds ratios (95% confidence intervals).

RESULTS

Of the 38 730 patients who were prospectively screened, 455 presented with a chief complaint of headache. Seventy-six percent were women, and the mean age was 37 years. Non-Hispanic whites were more likely diagnosed with migraine compared with Hispanics or African Americans (P<.001). Three percent had subarachnoid hemorrhage. Neurologist follow-up was ordered in 10%. The median time in the emergency department was 265 minutes. With the initial treatment, 44% resolved, 47% improved, and 9% had no change; none worsened. In comparison with all other therapies used, there was a trend suggesting the superiority of antiemetics (odds ratio, 2.66; 95% confidence interval, 0.81 to 8.61). Acetaminophen was less helpful (odds ratio, 0.27; 95% confidence interval, 0.10 to 0.70). When comparing specific agents to therapies which could be used at home, antiemetics led to headache resolution most often (odds ratio, 3.18; 95% confidence interval, 1.40 to 7.22); ketorolac showed a similar trend (odds ratio, 2.05; 95% confidence interval, 0.86 to 4.89).

CONCLUSIONS

Headache in the emergency department is a phenomena of young women who spend a long time waiting and receive many tests. A variety of therapies are used. Antiemetics may be especially useful for headache resolution.

Migraine: pharmacotherapy in the emergency department

Migraine can be a disabling condition for the sufferer. For the small number of patients for whom home therapy fails and who seek treatment in an emergency department, several therapeutic options are available. I review the evidence regarding the effectiveness and safety of the following therapies: the phenothiazines, lignocaine (lidocaine), ketorolac, the ergot alkaloids, metoclopramide hydrochloride, the "triptans," haloperidol, pethidine (meperidine hydrochloride), and magnesium sulfate. Based on available evidence, the most effective agents seem to be prochlorperazine, chlorpromazine and sumatriptan, each of which has achieved greater than 70% efficacy in several studies.

Emergency department management of pediatric migraine

Migraine is a common pediatric emergency department problem. Since its pathophysiology is unclear and possibly multifactorial, a single treatment strategy is unlikely to be successful for all patients. A specific treatment that has been successful for a particular patient should be strongly considered. Otherwise, it is best to start with simple therapies such as acetaminophen, aspirin, or an NSAID if not already tried at home. For patients requiring more specific therapy, reasonable choices would be dihydroergotamine or a dopamine antagonist such as prochlorperazine. There are several newer agents studied in adults with examples being sumatriptan and naratriptan. These probably have a role in the adolescent and should be considered in the younger age group when other therapies have failed. When the headache has been prolonged, dexamethasone may be useful in decreasing inflammation and relieving pain. As illustrated in many of the above studies, monotherapy is often inadequate in achieving complete relief of headache pain in all patients. Most of the drugs discussed here address only one of the three etiologies thought to be involved in migraine pathogenesis, namely; the dopaminergic system. the serotonin system or inflammation. Presumably, therapy directed toward more than one of these etiologies at the same time may be more effective (11).

Dopamine and migraine: a review of pharmacological, biochemical, neurophysiological, and therapeutic data

The dopamine theory of migraine pathogenesis, first proposed by F. Sicuteri in 1977, has attracted renewed interest after an increased frequency of the dopamine D2 receptor (DRD2) gene allele NcoI C was found in patients with migraine with aura. Therefore we reviewed the relevant literature. The most compelling argument favoring an interictal hypersensitivity of dopamine receptors in migraineurs stems from pharmacologic studies of the gastric and autonomic effects of dopaminergic agents such as apomorphine, but none of these studies was blinded and placebo-controlled. Various DRD2 antagonists abort migraine attacks after parenteral administration, while there is circumstantial evidence that dopamine agonists may be useful for prophylaxis. Most drugs used in these trials, however, lack selectivity for dopamine receptors. Both in pharmacological and therapeutic studies most patients had migraine without aura. We conclude that data suggesting a primary role for the dopaminergic system in migraine pathogenesis are unconvincing. Based on well established interactions between central amines, a reduced release of serotonin between attacks could lower dopamine release which would lead to receptor hypersensitivity.

Management of primary headache in emergency services of Santos and surrounding towns

OBJECTIVES

Primary headaches are often seen by Clinicians on duty at Emergency Services. We have investigated the treatment of such patients by 43 medical doctors who have been working at Emergency Services in the city of Santos and surrounding towns for many years.

RESULTS

We confirmed the high prevalence of primary headaches in Emergency Services. There seem to be diagnosis difficulties concerning differentiating attacks of migraine and tension type headache. We also observed that IV dipirone was the most frequently prescribed treatment for patients with primary headaches in this study. There is no protocol in the literature which recommends IV dipirone for the treatment of migraine attacks or other primary headaches.

CONCLUSION

It would be advisable to perform controlled double blind studies in order to verify the advantages of IV dipirone in the treatment of intense attacks primary headaches. We concluded that headache management recycling programs could be of interest for doctors who regularly work at Emergency Services.

A clinical review of the adaptive role of vasopressin in migraine

Vasopressin is a naturally available neuropeptide that subserves important vasomotor, antinociceptive, behavior control, fluid and electrolyte balance, platelet aggregation and blood coagulation functions. This review focuses on the clinical phenomena of migraine that are likely to influence vasopressin bioavailability or efficacy as well as the modulating influence of vasopressin itself. As part of a complex homeostatic adjustment to stress and pain, the intricacies of vasopressin metabolism may have particular relevance to the pathophysiology of migraine.

Intravenous chlorpromazine versus intramuscular sumatriptan for acute migraine

OBJECTIVE

To establish whether there is any difference in the efficacy of a chlorpromazine regimen and a sumatriptan regimen for the management of the pain of acute severe migraine.

SETTING

Two urban teaching hospital emergency departments.

METHODS

Prospective, randomised, unblinded, crossover trial. All patients received intravenous metoclopramide 10 mg and 1000 ml of normal saline over 1 h; 20 were then randomised to receive intramuscular sumatriptan 6 mg and 23 to receive intravenous chlorpromazine, 12.5 mg increments to a maximum of 37.5 mg. Response to treatment was measured using visual analogue pain scales.

RESULTS

No difference in efficacy between the sumatriptan regimen and the chlorpromazine regimen was found. Adverse effects were mild and equally distributed between the groups.

CONCLUSIONS

The chlorpromazine and sumatriptan regimens studied are both very effective for the relief of the headache of severe migraine.

Intramuscular prochlorperazine versus metoclopramide as single-agent therapy for the treatment of acute migraine headache

To compare the efficacy of intramuscular prochlorperazine and metoclopramide in the short-term treatment of migraine headache in the emergency department 86 eligible adult patients with moderate to severe migraine headache were evaluated prospectively at a university-affiliated community hospital. After randomization, each subject received a 2-mL intramuscular injection of sterile saline, prochlorperazine (10 mg), or metoclopramide (10 mg). No other analgesics were administered during the 60-minute study period; patient assessment of relief was followed using visual analog scales. Reduction in median headache scores was significantly better among those treated with prochlorperazine (67%) compared to metoclopramide (34%) or placebo (16%). Similarly, symptoms of nausea and vomiting were significantly relieved in the prochlorperazine group (chi 2 = 17.1, P < .001). However, rescue analgesic therapy was necessary in the majority of patients treated with prochlorperazine (16/28) and metoclopramide (23/29) after the 60-minute study period. Although intramuscular prochlorperazine appears to provides more effective relief than metoclopramide, these results do not recommend either drug as single-agent therapy for acute migraine headache.

Randomized, placebo-controlled evaluation of prochlorperazine versus metoclopramide for emergency department treatment of migraine headache

STUDY OBJECTIVE

To determine the comparative efficacy of i.v. metoclopramide and prochlorperazine for the initial emergency department treatment of migraine headache.

DESIGN

Prospective, randomized, double-blind, placebo-controlled trial.

SETTING

Military community hospital ED with an annual census of 75,000.

PARTICIPANTS

Seventy consenting adults from a convenience sample of patients presenting with migraine headache similar to that experienced in at least one prior episode. Exclusion criteria were pregnancy, fever, signs of meningismus, altered sensorium, drug or alcohol use, oxygen saturation less than 90%, recent trauma or seizure, "worst headache," abnormal blood pressure, recent (within 48 hours) use of metoclopramide or prochlorperazine, and allergy to metoclopramide or prochlorperazine.

INTERVENTIONS

In a random manner, each subject received a 2-mL i.v. injection of identical-appearing fluid containing metoclopramide (10 mg), prochlorperazine (10 mg), or saline solution (placebo). No other analgesics or medications were administered during the initial study period; rescue agents were administered by the choice of the treating physician after all data were collected.

MEASUREMENTS

Patients scored their nausea, pain, and sedation before receiving the 2-mL injections and at 30 minutes after injection. Ten-centimeter nonhatched visual analog scales were used for these measurements, with distance from the left end (zero) calculated for each use. Clinically important successful treatment was defined a priori as achievement of the following criteria: patient satisfaction and either a decrease of 50% or more in the 30-minute pain score (compared with the initial score) or an absolute pain score of 2.5 cm or less. Failure to achieve these criteria constituted treatment failure. Differences between groups were analyzed with the Kruskal-Wallis ANOVA and chi 2 tests. Data are reported as frequency percentages and median values, with a two-tailed P value of .05 or less considered significant.

RESULTS

Nausea, pain, and sedation scores were similar in all three groups before therapy. Thirty minutes after treatment, pain scores differed among those treated with prochlorperazine (1.1 cm), with metoclopramide (3.9 cm), and with placebo (6.1 cm, P = .003). Clinical success occurred more commonly after treatment with prochlorperazine (82%) than after metoclopramide (46%) or placebo (29%, P = .03). However, metoclopramide and placebo scores did not differ (P = .14). Nausea tended to be improved after prochlorperazine, compared with metoclopramide or placebo, at 30 minutes (P = .64). Four patients (6%) returned to the ED for relapse of migraine headache within 24 hours (three in the placebo group and one in the metoclopramide group).

CONCLUSION

i.v. prochlorperazine relieves the headache and tends to improve nausea better than metoclopramide in ED patients with acute migraine headache.

Parenteral chlorpromazine and a meningitis headache

Parenteral chlorpromazine is a frequently used agent in the acute management of tension and vascular headaches. However, headaches caused by other more serious diseases may also respond to this drug. This case report describes a patient with aseptic meningitis who experienced complete but temporary relief of her headache with parenteral chlorpromazine, prior to the eventual diagnosis.

Safety and efficacy of rectal prochlorperazine for the treatment of migraine in the emergency department

STUDY OBJECTIVE

To assess the safety and efficacy of rectal prochlorperazine in the treatment of acute migraines.

DESIGN

Randomized, double-blinded, placebo-controlled study.

SETTING

Emergency department of an inner-city university hospital.

PARTICIPANTS

ED patients with documented diagnosis of migraines.

INTERVENTIONS

Vital signs and level of alertness were monitored immediately before drug administration and 120 minutes after dosing. Pain intensity and adverse events were monitored immediately before drug administration and at 30, 60, and 120 minutes after dosing.

RESULTS

A positive outcome was defined as a pain score less than or equal to 5 on a 10-point scale or a 50% reduction in pain intensity from baseline at 120 minutes after dosing. All patients treated with prochlorperazine suppositories experienced a positive treatment outcome; only 50% of patients treated with placebo experienced a positive result at 120 minutes after dosing (P = .016). Pain intensity scores were significantly lower in the prochlorperazine group at 120 minutes (P = .018). There were no adverse reactions in either group, and there were no significant differences in vital signs or levels of alertness between groups. Patients who failed therapy were given rescue medication 120 minutes after dosing.

CONCLUSION

Prochlorperazine administered as a 25-mg rectal suppository provides excellent pain relief within 2 hours in patients with acute migraines.

An evaluation of the role of the ED in the management of migraine headaches

The objective of this study was to describe the characteristics and clinical course of patients who receive emergency department (ED) migraine treatment and their association with frequent ED visits. All migraine patient records during a 42-month period were reviewed retrospectively at an urban teaching hospital ED. One hundred eighty-five migraine patients had 339 total visits; 133 had a single visit; 31 had two visits; and 21 patients had three or more ED visits (range, 3 to 26 visits). Patients with three or more visits accounted for 42.5% of all ED migraine visits. Drugs were administered in 82.3%, and efficacy was documented in 49% of ED visits. Complete or considerable relief was noted in 64.5% of visits. Drug abuse was infrequently identified in migraine patients. Most migraine patients seem to use the ED appropriately. A small group (11.4%) of patients accounted for 42.5% of all ED visits. Given the nature of severe, frequent migraines and the current lack of consistently effective therapy, this may be a common ED phenomenon. More effective management strategies and therapy that will enable patients to reduce their dependence on the ED for treatment would be useful for patients with multiple ED visits.

The pharmacologic treatment of acute migraine headaches

Pharmacologic agents useful in the treatment of acute migraine headaches include nonsteroidal antiinflammatory drugs (NSAIDs), ergotamines, and analgesics. Parenteral ergotamines, antiemetics, NSAIDs, corticosteroids, and sumatriptan can be successfully administered in the office or emergency room setting. In this article, evidence regarding the efficacy of these agents is reviewed.

A double-blind comparison of granisetron and placebo for the treatment of acute migraine in the emergency department

Three hundred and ninety-seven patients who presented to the emergency department were screened for a randomized, double-blind, placebo-controlled study of iv granisetron (40 micrograms/kg or 80 micrograms/kg) in acute migraine. Twenty-eight patients fulfilled the stringent eligibility criteria and completed the study. Rescue medication was required 2 h post-infusion in 8 of 10 patients receiving granisetron 40 micrograms/kg, 5 of 10 patients receiving granisetron 80 micrograms/kg, and 6 of 8 patients receiving placebo. Significant improvement (p less than 0.05) in headache pain (on a visual analogue scale and categorical scale) was observed in the 80-micrograms/kg group. Headache pain evaluated with the Hunter headache scale indicated improvement for the sensory and affective components of headache pain in both granisetron groups. Except for more nausea at 30 min in the placebo group, no significant differences were noted between treatments. All three treatments were well tolerated. Granisetron may be effective for acute migraine headache; however, further studies with increased patient numbers are required.

Methotrimeprazine versus meperidine and dimenhydrinate in the treatment of severe migraine: a randomized, controlled trial

STUDY OBJECTIVE

To compare the effectiveness of IM administration of methotrimeprazine, a non-narcotic, nonaddicting phenothiazine derivative, with that of a combination of meperidine and dimenhydrinate in the treatment of severe migraine.

DESIGN

Double-blind, randomized, controlled trial.

SETTING

University hospital emergency department.

PARTICIPANTS

Consecutive adult patients with migraine who met eligibility criteria.

INTERVENTIONS

Random allocation to receive IM injections of either 37.5 mg methotrimeprazine (Levoprome, Nozinan) or 75 mg meperidine (Demerol) combined with 50 mg dimenhydrinate (Dramamine, Gravol).

MEASUREMENTS AND MAIN RESULTS

The 37 patients in each group who completed the study were similar in all demographic and clinical characteristics. There were no statistical differences in pain intensity one hour after treatment, change in pain intensity, or pain relief as measured on a visual-analog scale; need for additional analgesia; persistence of nausea or vomiting; adverse effects; or follow-up status, except for prolonged drowsiness, in the group receiving methotrimeprazine.

CONCLUSION

Methotrimeprazine is comparable to meperidine with dimenhydrinate for treating severe migraine and may be considered an effective, nonaddicting, IM alternative to narcotics for the management of this problem.

Refusal of care and discharging 'difficult' patients from the emergency department

Patients generally have the right to refuse medical care, a right based on certain legal precedents. Its application in the emergency department leads to difficult decisions for the emergency physician. A model that allows the emergency physician to determine the capacity of a patient to refuse care is presented. Certain types of patients regularly present problems in their treatment. These include psychiatric patients, narcotics abusers, alcoholics, "street people," and some patients with migraine headaches. They represent some of our most difficult decisions because the treatment required for the patient is often clear and the patient refuses care or demands inappropriate care.

Comparative efficacy of chlorpromazine and meperidine with dimenhydrinate in migraine headache

Approximately 20% of the population suffers from migraine headache, and a significant number develop "fixed" migraines, refractory to oral medications. Of this group, many become habitual narcotic users. A previously published case series using IV chlorpromazine suggested efficacy, so a randomized, double-blind, controlled trial was conducted. The study compared IV chlorpromazine against IV meperidine with dimenhydrinate. Entry criteria were emergency department patients from 18 to 60 years of age with a clinical diagnosis of common or classic migraine headache. After informed consent was obtained, an IV line with normal saline was established, and a bolus of 5 mL/kg was administered. Patients were randomized into two groups: chlorpromazine and meperidine with dimenhydrinate. The chlorpromazine group received a bolus injection of 5 mL normal saline placebo followed by 0.4 mL/kg chlorpromazine solution (0.1 mg/kg). The chlorpromazine was repeated every 15 minutes as needed up to a total of three doses. The meperidine with dimenhydrinate group received 5 mL dimenhydrinate solution (25 mg) followed by 0.04 mL/kg meperidine (0.4 mg/kg). Again, the meperidine solution was repeated in the same dosage every 15 minutes as needed up to a total of three doses. If response was inadequate 15 minutes after the third dose, the sequence was broken, and the other medication given. Blood pressure and response were assessed at 15-minute intervals for one hour. Pain was assessed by both visual and verbal analogue scales every 15 minutes. In all, 46 patients were entered in the study (24 chlorpromazine and 22 meperidine with dimenhydrinate).(ABSTRACT TRUNCATED AT 250 WORDS)