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Acute Migraine Treatment in Emergency Settings

Clinician Summary – Sept. 19, 2013

Acute Migraine Treatment in Emergency Settings

Formats

Table of Contents

Research Focus for Clinicians

In response to a request from the public about treatment of adults with migraines in emergency departments (EDs) or other emergency settings, the Agency for Healthcare Research and Quality (AHRQ) funded the University of Alberta Evidence-based Practice Center to develop a systematic review of the literature to summarize the evidence regarding the comparative effectiveness of parenteral medicines for adults who present to the ED with migraine. The systematic review included 71 clinical studies published through January 5, 2012. This summary is provided to assist in decisionmaking along with a patient’s values and preferences. Reviews of evidence should not be construed to represent clinical recommendations or guidelines. The full report can be accessed on the right side of this Web page.

Background

Acute migraine headaches can last from 4 hours to 3 days if untreated. Migraines often require bed rest, pain medications, and time off from work and other activities, thus reducing an individual’s productivity and quality of life. Seven percent of U.S. migraine patients reported using an ED or urgent care center for treatment within the previous 12 months. Of patients who use an ED for migraine treatment, 19 percent make multiple visits over the course of 1 year. Practice patterns of migraine treatment in the emergency setting vary in the United States. As many as 20 different agents are commonly used to treat acute migraines in the ED. A synthesis of the evidence from the clinical literature may inform treatment choices based on the balance of benefits and adverse effects of parenteral agents for treating acute migraine.

Conclusions

  • Several common parenteral treatments for migraine pain (e.g., sumatriptan, metoclopramide, neuroleptics, and nonsteroidal anti-inflammatory drugs [NSAIDs]) in EDs are effective at reducing pain intensity and/or achieving pain-free status within 1–2 hours of administration.
  • Direct head-to-head comparisons are very limited; however, moderate-strength evidence suggests that droperidol may provide full headache relief better than prochlorperazine.
  • Low-strength evidence from indirect comparisons made across trials using statistical techniques to assess pain reduction suggests that dihydroergotamine (DHE), in combination with either prochlorperazine or metoclopramide, and neuroleptic monotherapy are the most effective (approximately a 40-mm reduction on a 100-point visual analog scale [VAS]).
  • Patients who receive dexamethasone plus abortive therapy are less likely to have a recurrence.
  • Most adverse effects are minor and self-limiting; however, the data on pain relief must be weighed carefully with the data on side effects, especially akathisia, which is associated more with the neuroleptics and metoclopramide.

Clinical Bottom Line

Ability To Achieve Pain-Free Status

Ability To Provide Significant Headache Relief (Complete or Partial Relief)

Neuroleptics and sumatriptan provide significant headache relief at various time points versus placebo. evidence medium

Ability To Reduce Pain Intensity

Pain intensity measurements at time points after administration are reported as the mean difference (MD) versus placebo on a 100-point VAS (in mm)*.

Ability To Prevent Recurrence**

Indirect Comparisons Performed Across Controlled Clinical Trials Using Statistical Methods

Adverse Effects

Strength of Evidence Scale

High: evidence high
High confidence that the evidence reflects the true effect. Further research is very unlikely to change our confidence in the estimate of effect.

Moderate: evidence medium
Moderate confidence that the evidence reflects the true effect. Further research may change our confidence in the estimate of effect and may change the estimate.

Low: evidence low
Low confidence that the evidence reflects the true effect. Further research is likely to change our confidence in the estimate of effect and is likely to change the estimate.

Insufficient:evidence insufficient
Evidence is either unavailable or does not permit a conclusion.

* All pain scales are subjective, numerical, and anchored by “severe” and “none” extremes. Pain scores in any format other than the VAS (in mm) were converted to a 100-point scale for comparative purposes across studies.
** Recurrence is defined as the return of headache in the followup period after successful initial treatment in the ED.
This group of drugs were not easily classified and were infrequently studied (i.e., hydroxyzine, lidocaine, magnesium sulfate, octreotide, and sodium valproate).
95% CI = 95-percent confidence interval; FDA = U.S. Food and Drug Administration; IV = intravenous; RR = relative risk

Gaps in Knowledge

  • More head-to-head comparisons are needed to determine which treatments are most effective in quickly reducing migraine pain, achieving pain-free status, and reducing the likelihood of recurrence.
  • The effects of sex, race, or duration of headache on the response to treatment should be investigated.
  • The differences in effectiveness between the various parenteral delivery routes (intravenous, intramuscular, and subcutaneous) should be further explored.

What To Discuss With Your Patients

  • The effectiveness of chosen treatments
  • Evidence of adverse effects
  • Reasons for using combination therapy
  • Use of dexamethasone to prevent relapse
  • The availability of treatments for chronic migraine to prevent recurrent emergency treatment

Resource for Patients

Treating Severe Migraine Headaches in the Emergency Room, A Review of the Research for Adults is a free companion to this clinician research summary. It can help patients talk with their health care professionals about treatment options. It provides information about:

  • Migraine headaches
  • When to visit the emergency room
  • Benefits and possible side effects of migraine headache treatments
  • Questions to discuss with their doctor

Source

The information in this summary is based on Acute Migraine Treatment in Emergency Settings, Comparative Effectiveness Review No. 84, prepared by the University of Alberta Evidence-based Practice Center under Contract No. 290-2007-10021-I for the Agency for Healthcare Research and Quality, November 2012. This summary was prepared by the John M. Eisenberg Center for Clinical Decisions and Communications Science at Baylor College of Medicine, Houston, TX. It was written by Andrea D. Humphries, Ph.D., Joseph S. Kass, M.D., J.D., and Michael Fordis, M.D.

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