Assessment of Medications Used to Treat Migraine in the ER

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Emergency room visits are not the best solution for migraine treatment. When we need care, it truly is best if we can receive it from our own doctors.

Still, there may be times when we have no choice but to seek migraine treatment from an emergency room. Annually, there are 1.2 million visits made to emergency rooms in the United States for acute migraine treatment. There are several issues that migraine patients may encounter in the emergency room. Among those problems is that emergency room physicians often don't know the best treatment options for migraine.

A recent assessment article in the journal Headache provides evidence-based information to help doctors in emergency departments do a better job treating migraine patients.

The Assessment Objective:

"To provide evidence-based treatment recommendations for adults with acute migraine who require treatment with injectable medication in an emergency department (ED). We addressed two clinically relevant questions: (1) Which injectable medications should be considered first-line treatment for adults who present to an ED with acute migraine? (2) Do parenteral corticosteroids prevent recurrence of migraine in adults discharged from an ED?"

Assessment Methods:

The American Headache Society convened an expert panel of authors for this assessment. They:

  • consulted with a medical research librarian and defined a search strategy.
  • performed a search of Medline, Embase, the Cochrane database and clinical trial registries from inception through 2015.

For their first question - identified studies of adults with acute migraine in which an injectable therapeutic was compared to placebo or to an active control.

The accepted routes of medication delivery included intravenous, intramuscular, and subcutaneous injections.

For their second question, researchers identified adults with acute migraine in which a corticosteroid medication was compared to placebo.

The panel then rated chosen articles using the American Academy of Neurology’s risk of bias tool. For each medication, the members of the panel determined likelihood of efficacy. The panel's recommendations were created accounting for:

  • efficacy,
  • adverse events,
  • availability of alternate therapies, and
  • principles of medication action.

Assessment Results/Conclusions:

The panel's search identified 68 unique randomized controlled trials that utilized 28 injectable medications.

  • Metoclopramide, prochlorperazine, and sumatriptan each had multiple class 1 studies supporting acute efficacy, as did dexamethasone for prevention of migraine recurrence.
  • All other medications had lower levels of evidence.

Recommendations and Conclusions Based on the Assessment:

Injectable medications that "should be offered" to adults coming to the ER for a migraine:

  • intravenous metoclopramide (Reglan),
  • intravenous prochlorperazine (Compazine), and
  • subcutaneous sumatriptan (Imitrex).
  • Dexamethasone (a corticosteroid) should be offered to these patients to prevent recurrence of migraine.

There were a number of recommendations for injectable medications that "may be offered" to adults coming to the ER for a migraine, including:

  • intravenous acetaminophen,
  • intravenous acetylsalicylic acid (aspirin),
  • intravenous diclofenac,
  • intravenous ketorolac (Toradol),
  • intravenous valproate (Depakote).

The Findings:

"While many patients are satisfied with the headache relief they obtain in the ED, inadequate relief, adverse medication events, and recurrence of headache after ED discharge are very common. Using a standardized methodology, we hope that ED-based researchers continue to conduct and publish randomized trials of migraine therapeutics to optimize the injectable treatment that migraine patients receive in the ED."

Summary and Implications for Patients:

Migraine treatment in the emergency room or emergency department is inconsistent at best. Since there's no diagnostic test to confirm migraine, it's one of the top complaints used by people who go to the ER as drug seekers. That can cuase problems for legitimate migraine patients. Add to that the fact that many doctors know very little about migraine treatment, and seeking ER care for a migraine can turn into a "perfect storm" of stigma, loss of dignity, and little relief.

This evidence-based assessment did what busy ER physicians can't do. It looked at 68 clinical trials that utilized 28 injectable medications and evaluated the evidence for their effectiveness. Their work is laudable. The question at this point is whether the results will be utilized by ER physicians.

See more helpful articles:

Migraine and the ER - Not the Best Solution

When to See a Doctor for a Migraine or Headache

Sources:

Orr, Serena L., MD: Friedman, Benjamin W., MD, MS; Christie, Suzanne, MD, FRCPD; Minen, Mia T., MD; Bamford, Cynthia, MD; Kelley, MD, PhD; Tepper, Deborah. "Management of Adults With Acute Migraine in the Emergency Department: The American Headache Society Evidence Assessment of Parenteral Pharmacotheraphies." Headache 2016;56:911-940.