What is a migraine, anyway, and when is it gone?

Do ED patients with migraine headaches meet internationally accepted criteria?

A recent editorial criticized emergency medicine researchers who study the treatment of acute migraine for failing to standardize patients according to definitions provided by the International Headache Society (IHS). In fact, most emergency medicine-based studies of migraine therapies have not used IHS Criteria (IHSC) for patient inclusion and are not uniform in the definition of acute migraine. The purpose of this study was to determine the percentage of patients with complaint of headache who present to the emergency department with a prior diagnosis of migraine and/or emergency department discharge diagnosis of acute migraine that meet IHSC. The study was a prospective observational study performed in a community-based and consisted of consecutive patients with a chief complaint of headache who presented to any 1 of 6 study investigators. Patients recorded historical data on a standard form; Clinical data were recorded by the investigators. Ninety-five percent confidence intervals and the Fisher exact test were calculated as appropriate. One hundred eighty-five patients were enrolled (study group): 70% were women, 43% had prior imaging studies to diagnose the etiology of the headache, and 26% had a diagnostic workup during the current emergency department visit; the probable headache etiology was found in 12 of these cases. Only 3 patients that had an ED workup that fit IHSC. Forty-nine percent of all patients had a prior diagnosis of migraines; 41 of these patients (45%) met IHSC. Forty-two percent of all patients had an emergency discharge diagnosis of acute migraine; of these, 43 (56%) met IHSC. Forty-four out of 96 (46%; 95% confidence interval = 35%-57%) patients with a prior diagnosis of migraine and/or discharge diagnosis of acute migraine met IHSC. Modification of the IHSC, by removing restrictions for headache duration and number of prior episodes, would have markedly increased the percentage of patients with a previous migraine and/or emergency discharge diagnosis of acute migraine that met other qualitative IHSC (94%). Of the patients with prior migraine diagnosis and/or emergency department diagnosis of acute migraine, men and women were equally as likely to meet IHSC (41% v 48%, P = 0.79). Less than half of patients with a prior diagnosis and/or final emergency discharge diagnosis of acute migraine met IHSC. Our findings raise concerns about the external validity of prior emergency department-based research of acute migraine therapy and the utility of the IHSC for future research. Modification of the IHSC for emergency medicine research should be considered.

A randomized clinical trial to assess the efficacy of intramuscular droperidol for the treatment of acute migraine headache

In a recent case series, we reported that intramuscular droperidol appeared to be an effective therapy for the treatment of acute migraine headache. The objective of the study was to further assess the efficacy of intramuscular droperidol for the treatment of acute migraine headache. The study design was a randomized, clinical trial set in a community-based ED. The population was a convenience sample of ED patients who met International Headache Society acute migraine criteria. Exclusions included pregnancy, use of narcotic or phenothiazine medications within 24 hours. For the protocol, patients were randomized to 1 of 2 treatment groups. Patients and physicians were blinded as to the treatment provided. Patients recorded their initial pain on a 100mm Visual Analog Scale (VAS) Patients were randomized to receive either 2.5 mg droperidol intramuscularly; the other group received 1.5 mg/kg meperidine intramuscularly. After 30 minutes patients recorded their pain on the VAS and recorded their preference for the medication on a Likert Scale. Physicians recorded the incidence of any side effects and the need for rescue medication. Statistical analysis consisted of categorical variables that were analyzed by chi-square, continuous interval data by t-tests and ordinal data by Mann-Whitney U test. The primary outcome parameters were mean VAS score change and the percentage of patients who wanted to go home without rescue medication. The study had an 80% power to detect a 26 mm difference in the mean change in VAS between groups. Of the 29 patients who were enrolled, 15 received droperidol. Both groups were similar with respect to age (30.7 +/- 8.9 years droperdol v 32.7 +/- 9.9 years meperidine; P =.59), female sex (73% v 71%; P =.91), mean headache duration (24.7 +/- 28.3 v 18.3 +/- 25.8 hours; P =.55). The droperidol group had a higher mean initial VAS score (88 v 76 mm; P =.03). The 2 groups were similar with regard to outcome, including: mean change in VAS score (47 v 37 mm; P =.33), average Likert score (1.1 v 1.9; P =.85), and the percentage of patients who did not want rescue medication (67% v 57%; P =.61). The incidence of sedation was 6.7 v 14.3%. Akathisia occurred in 13.3% of pts who received droperidol. We found that intramuscular droperidol was similar in efficacy to meperidine with a low incidence of side effects.