Migraine Rx in the ED: A Systematic Review

Migraine headache accounts for at least one-third of the 5,000,000 headache visits to US emergency departments each year. In the acute care setting there is currently significant heterogeneity in the treatment of acute migraine. This practice variation can result in patients being treated with medications that may be ineffective and can contribute to prolonged ED stay, poor patient outcomes, return visits to the ED, and worsening of the migraine pattern.

Recently a systematic review examined the available literature on acute care treatments for migraine for effectiveness and tolerability, graded each medication’s level of available evidence, and gave recommendations regarding its use.¹ The review was limited to double-blind prospective RCTs in adults treated in an emergency department or equivalent acute care setting. Only studies that defined migraine using either International Headache Society diagnostic criteria or the Ad Hoc criteria were included. Overall 831 abstracts were screened, 120 full text articles were assessed resulting in a total of 44 studies included in the review. Each study was graded according to risk for bias and given a final rating of methodological quality using the US Preventative Task Force criteria.

Recommendations regarding use of each treatment were made at a consensus meeting of the Canadian Headache Society. This expert consensus group reviewed each treatment based on several additional factors including desirable and undesirable side effects, variability in patient values or preferences, and wise use of resources. The level of quality of evidence had partial impact on the use recommendation. Final use recommendation was graded as strong or weak based on review of these additional factors. The pertinent results are summarized in the Table.

Five therapies (4 available in the US) with high to low levels of evidence gained a strong recommendation for use.

Prochlorperazine (Compazine) carried the highest level of evidence based on 2 “good,” 3 “fair,” and 1”poor” trials. The authors note that although strongly effective, this should be weighed against the relative frequent occurrence of extrapyramidal symptoms (EPS). In one study, EPS occurred in both prochlorperazine and metoclopramide groups in 13% of treated subjects. To address this, consideration of coadministration with an agent such as diphenhydramine is advised.

Subcutaneous sumatriptan was the only triptan medication assessed in this review. While carrying a strong recommendation, it is more likely to be efficacious when given in the first few hours after the onset of a migraine attack and is limited to patients who have not used a triptan in the last 24 hours. Despite their effectiveness, triptans are currently underutilized; a recent analysis of a National Hospital Ambulatory Medical survey found a triptan medication was given only in 7% of acute migraine treatments in the ED. Additionally when a triptan was used, the median length of ED stay was shorter than when opiate therapy was administered.²

Ketorolac (IM or IV) was strongly recommended after 2 “fair” and 2 “poor” quality studies with active comparators.

One of the more striking results of the review is the recognition that the evidence on comparative efficacy of available options is generally of low quality. Many treatments received weak recommendations based on the very limited evidence available.  

Meperidine (Demerol) received a weak recommendation based on 1 “fair” and 1 “poor” study. Despite falling softly into the "use" category, meperidine is becoming much less available due to concerns of serious adverse events, including seizure. It is recommended that this drug be used with caution.

Routine use of opioids has long been advised against for acute migraine.³

The limitation in scope of this review was again demonstrated in the evaluation of dexamethasone. This medication received a strong recommendation with moderate evidence that it is not effective in acute treatment. However some evidence suggests that a single dose acutely will decrease the relative risk of migraine recurrence 26% over the first 72 hours, overall making it potentially beneficial outside of its immediate effect.⁴

Overall this systematic review is a substantial step forward in establishing an evidence-based approach to migraine treatment in the acute care setting. It demonstrates that there is significant need for further research. While clinicians should exercise judgment based on each individual patient and circumstance, this review provides an excellent evidence based guide.

Table.

References:

1. Orr SL, Aube M, Becker WJ, et al. Canadian Headache Society systematic review and recommendations on the treatment of migraine pain in emergency settings. Cephalalgia. 2014; Epub ahead of print. 1-14.
2. Friedman BW, West J, Vinson DR, et al. Current management of migraine in US emergency departments: An analysis of the National Hospital Ambulatory Medical Care Survey. Cephalalgia. 2014; Epub ahead of print. 1-9.
3. Loder E, Weizenbaum E, Frishberg B, et al. Choosing wisely in headache medicine: the American Headache Society’s list of five things physicians and patients should question. Headache. 2013; 53: 1651–1659.
4. Colman I, Friedman BW, Brown MD, et al. Parenteral dexamethasone for acute severe migraine headache: meta-analysis of randomised controlled trials for preventing recurrence.BMJ. 2008;336: 1359-1361.