Friday, June 17, 2016

Management of acute migraine in the emergency department

Orr SL, Friedman BW, Christie S, Minen MT, Bamford C, Kelley NE, Tepper D.
Management of Adults With Acute Migraine in the Emergency Department: The
American Headache Society Evidence Assessment of Parenteral Pharmacotherapies.
Headache. 2016 Jun;56(6):911-40.


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?
The American Headache Society convened an expert panel of authors who defined a search strategy and then performed a search of Medline, Embase, the Cochrane database and clinical trial registries from inception through 2015. Identified articles were rated using the American Academy of Neurology's risk of bias tool. For each medication, the expert panel determined likelihood of efficacy. Recommendations were created accounting for efficacy, adverse events, availability of alternate therapies, and principles of medication action.
The search identified 68 unique randomized controlled trials utilizing 28 injectable medications. Of these, 19 were rated class 1 (low risk of bias), 21 were rated class 2 (higher risk of bias), and 28 were rated class 3 (highest risk of bias). Metoclopramide, prochlorperazine, and sumatriptan each had multiple class 1 studies supporting acute efficacy, as did dexamethasone for prevention of headache recurrence. All other medications had lower levels of evidence.
Intravenous metoclopramide and prochlorperazine, and subcutaneous sumatriptan should be offered to eligible adults who present to an ED with acute migraine (Should offer-Level B). Dexamethasone should be offered to these patients to prevent recurrence of headache (Should offer-Level B). Because of lack of evidence demonstrating efficacy and concern about sub-acute or long-term sequelae, injectable morphine and hydromorphone are best avoided as first-line therapy (May avoid-Level C).

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1 comment:

  1. Emergency physicians should use any of three drugs as first-line treatments for migraine in the emergency department (ED), according to a new guideline.

    A literature review found evidence of efficacy and safety for intravenous metoclopramide, intravenous prochlorperazine, and subcutaneous sumatriptan to treat these patients' headache pain, prompting a Level B recommendation, Mia Minen, MD, of NYU Langone Medical Center in New York City, and colleagues reported online in Headache.

    However, opioids -- injectable morphine and hydromorphone -- should be avoided, they said…

    Although no medications received a Level-A "must offer" recommendation, the three aforementioned drugs received a Level-B "should offer" recommendation, based on class 1 evidence, the researchers said.

    The corticosteroid dexamethasone received the same level recommendation to be given to patients in order to prevent migraine recurrence, they reported.

    Other drugs with a Level-C "offer" recommendation included acetaminophen, acetylsalicylic acid, chlorpromazine, dexketoprofen, diclofenac, dipyrone, droperidol, haloperidol, ketorolac, and valproate.

    In addition to avoiding the opioids for migraine treatment in the ED, the researchers also advised passing on diphenhydramine, lidocaine, and octreotide…

    Stephen Silberstein, MD, of the Jefferson Headache Center in Philadelphia, noted in an accompanying editorial that the "fundamental problem of guidelines that want to comment on old drugs [is that] there are few, if any, studies. The old maxim applies: lack of evidence does not mean lack of efficacy."

    "What we need is more controlled trials of medications in the borderland of uncertainty and more studies in personalized medicine," Silberstein wrote.