Migraine in the ED: Prochlorperazine More Effective Than Hydromorphone

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The use of opioids for acute treatment of Migraine and the treatment of Migraine in the emergency department (ED) are common topics of discussion in the Migraine community. Research presented at the 2017 scientific meeting of the American Headache Society touched on both topics.

Hydromorphone (brand name Dilaudid) is currently administered in 25 percent of all emergency department visits for Migraine. One problem with this is the research showing that opioids aren’t good treatments for Migraine. Any use of opioids increases the risk of episodic Migraine progressing to chronic Migraine. If a patient’s Migraines are already chronic, the use of opioids inhibits the transition back to episodic.

The study:

Study methods:

  • Randomized, double-blind comparative effectiveness study
  • Conducted in two emergency departments in New York City
  • Patients were eligible for the study if:
  1. They met the criteria for Migraine under the International Classification of Headache Disorders, 3rd edition.
  2. Their attending physicians had no concerns about secondary headache (headache caused by another condition).
  3. They hadn’t used an opioid within the previous month.
  • Patients were randomized and were given either:
  1. Prochlorperazine (brand name Compazine discontinued), 10mg and diphenhydramine (Benadryl), 25mg, administered intravenously over five minutes
  2. Hydromorphone, 1mg, administered intravenously over five minutes
  • Patients could elect to receive a second dose of study medication after one hour.
  • Primary outcome: sustained relief achieving a headache level of mild or none within two hours and maintaining that level for 48 hours after only one dose of study medication and no rescue medication.

Study results:

  • Trial was halted by the data-monitoring committee after 127 patients had been enrolled
  • The primary outcome was achieved:
  1. by 60 percent of the patients in the prochlorperazine arm of the study after one dose
  2. by 31 percent of the participants in the hydromorphone arm of the study after one dose

Study conclusion:

“Intravenous hydromorphone is substantially less effective than intravenous prochlorperazine for the treatment of acute migraine in the ED.”

Comments and implications for patients:

The results of this study are quite clear. The IV prochlorperazine and diphenhydramine treatment was nearly twice as effective as the hydromorphone treatment.

This holds great significance for Migraine patients who need to seek Migraine treatment in the emergency department. For too many years, Migraine and the treatment of Migraine were poorly understood. Opioids were routinely given to Migraine patients in the emergency department because they stopped the pain, and doctors weren’t yet aware of the issues with opioids and Migraine chronicity.

Setting aside all of today’s issues with opioid abuse, and concentrating only on what treatments are best for both short- and long-term use, this study clearly shows that we have viable options other than opioids.

It’s good to see this evidence of the effectiveness of IV prochlorperazine. Several years ago, I had to go to the ED with a Migraine. The doctor asked me if anyone had ever given me IV prochlorperazine for a Migraine. When I told him, “No,” he told me he’d seen some amazing results with it. He had the nurse put an IV port in the back of my hand, saying that would keep them from having to stick me twice if it didn’t work for me.

It was amazing. Within 20 minutes, my Migraine was totally gone. As the doctor explained to me that night, there are some medications that aren’t categorized as Migraine abortives that can, when administered via IV, abort a Migraine. Having another tool in our Migraine toolbox is great!

Source:

Friedman B, Irizarry E, Rosa K. A Randomized Study of Prochlorperazine versus Hydromorphone for Acute Migraine. Research paper presentation. American Headache Society Scientific Meeting. June, 2017.

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