Parenteral Dihydroergotamine for Acute Migraine Headache: A Systematic Review of the Literature

STUDY OBJECTIVE

Many therapies are used in the treatment of acute migraine headache, with little agreement on effectiveness. This systematic review is designed to determine the effectiveness of parenteral dihydroergotamine in reducing pain, nausea, and relapse for episodes of acute migraine in adults.

METHODS

Randomized controlled trials were identified using MEDLINE, EMBASE, other computerized databases, hand searching, bibliographies, and contacts with industry and authors. Studies in which dihydroergotamine (alone or in combination with an antiemetic) was compared with placebo or any other common migraine therapy were considered. Relevance, inclusion, and study quality were assessed independently by 2 reviewers.

RESULTS

From 281 potentially relevant abstracts, 11 studies met the inclusion criteria. Solitary dihydroergotamine use was compared to sumatriptan and phenothiazines in 3 studies; results failed to demonstrate a significant benefit of dihydroergotamine over these therapies. In 8 combination treatment studies, heterogeneity in study methodology prevented statistical pooling. However, dihydroergotamine administered with an antiemetic was as effective as or more effective than meperidine, valproate, or ketorolac across all pain, nausea, and relapse outcomes reported in all studies.

CONCLUSION

This evidence suggests that dihydroergotamine is not as effective as sumatriptan or phenothiazines as a single agent for treatment of acute migraine headache; however, when administered with an antiemetic, dihydroergotamine appears to be as effective as opiates, ketorolac, or valproate. Given its nonnarcotic properties, parenteral dihydroergotamine combined with an antiemetic should be considered as effective initial therapy in clinical practice.

Parenteral metoclopramide for acute migraine: meta-analysis of randomised controlled trials

OBJECTIVE

To assess the evidence from controlled trials on the efficacy and tolerability of parenteral metoclopramide for acute migraine in adults.

DATA SOURCES

Cochrane Central Register of Controlled Trials, Medline, Embase, LILACS, CINAHL, conference proceedings, clinical practice guidelines, and other sources.

SELECTION CRITERIA

Randomised controlled trials of parenteral metoclopramide for acute migraine in adults.

RESULTS

We reviewed 596 potentially relevant abstracts and found 13 eligible trials totalling 655 adults. In studies comparing metoclopramide with placebo, metoclopramide was more likely to provide significant reduction in migraine pain (odds ratio 2.84, 95% confidence interval 1.05 to 7.68). Used as the only agent, metoclopramide showed mixed effectiveness when compared with other single agents. Heterogeneity of studies for combination treatment prevented statistical pooling. Treatments that did include metoclopramide were as, or more, effective than comparison treatments for pain, nausea, and relapse outcomes reported in all studies.

CONCLUSIONS

Metoclopramide is an effective treatment for migraine headache and may be effective when combined with other treatments. Given its non-narcotic and antiemetic properties, metoclopramide should be considered a primary agent in the treatment of acute migraines in emergency departments.

Supporting clinical practice at the bedside using wireless technology

OBJECTIVES

Despite studies that show improvements in both standards of care and outcomes with the judicious application of clinical practice guidelines (CPGs), their clinical utilization remains low. This randomized controlled trial examined the use of a wirelessly networked mobile computer (MC) by physicians at the bedside with access to an emergency department information system, decision support tools (DSTs), and other software options.

METHODS

Each of ten volunteer emergency physicians was randomized using a matched-pair design to work five shifts in standard fashion (desktop computer [DC] access) and five shifts with a wirelessly networked MC. Work pattern issues and electronic CPG/DST use were compared using end-of-shift satisfaction questionnaires and review of a CPG/DST database. Repeated-measures analysis of variance was used to examine between-shift differences.

RESULTS

A total of 100 eight-hour shifts were evaluated; 99% compliance with postshift questionnaires was achieved. Using a seven-point Likert scale (MC values first), MCs were rated as being as fast (5.04 vs. 4.54; p=0.13) and convenient (5.08 vs. 4.14; p=0.07) as DCs. Overall, physicians rated MCs to be less efficient (3.18 vs. 4.30; p=0.02) but encouraged more frequent use of DSTs (4.10 vs. 3.47; p=0.03) without impacting doctor-patient communication (2.78 vs. 2.96; p=0.51). During the study period, physician use of an intranet Web application (eCPG) was more frequent during shifts assigned to the MC when compared with the DC (eCPG uses/shift, 3.6 vs. 2.0; p=0.033).

CONCLUSIONS

The MC technology permitted physicians to access information at the bedside and increased the use of CPG/DST tools. According to physicians, patients appeared to accept their use of information technology to assist in decision making. Development of improved computer technology may address the major limitation of MC portability.

Birth cohort studies in psychiatry: beginning at the beginning

Longitudinal formulations of psychiatric illness have long been familiar. In the 19th century, Thomas Clouston wrote about developmental insanity in young men, presaging modern views of schizophrenia as having some of its origins or first manifestations in early life (Clouston, 1891; O'Connell et al. 1997). At the same time, Sigmund Freud was creating his system of psychoanalysis to understand hysterical conversion and other aspects of adult psychology as sequelae of early psychological events. Now, within an epidemiological and neuroscientific framework, we are beginning to understand that a variety of psychiatric disorders, including those of later life, such as cognitive decline and dementia may be the final common pathway of a long chain of mutable events (Richards et al. 2004). Just as in clinical neurology, where one is taught to place the causal lesion as high as possible so, too, in psychiatry we should look for the seeds of causality earlier rather than later in life.

Use of narcotic analgesics in the emergency department treatment of migraine headache

OBJECTIVE

Treatment of acute migraine headache with narcotics is potentially ineffective and may lead to abuse. The authors examined the treatment practice variation across five linked EDs in one Canadian center, focusing on the use of narcotic analgesics and factors associated with their use.

METHODS

Five hundred acute migraine headache patient charts were randomly selected from five Canadian EDs. Charts underwent a structured review to determine medication use. Data were analyzed, comparing those who received narcotics as first-line treatment with those who did not, using chi(2) and t-tests and logistic regression.

RESULTS

The majority of patients (59.6%) received narcotics as first-line treatment. Numerous factors were associated with first-line narcotic treatment. Having taken antiheadache medications prior to ED presentation (odds ratio [OR]: 2.63; 95% CI: 1.53, 4.51) and hospital of presentation being other than Hospital A (e.g., Hospital D, OR: 6.32; 95% CI: 2.76, 14.46) increased the odds of receiving first-line narcotics. Having received a more urgent triage score (OR: 0.4; 95% CI: 0.24, 0.65) or having a longer duration of headache (OR: 0.994; 95% CI: 0.99, 0.99) decreased the odds of receiving first-line narcotics.

CONCLUSIONS

Acute migraine management in these EDs does not meet current consensus guidelines. Factors associated with narcotic use are predictable, and a concerted effort to replace narcotics with more evidence-based first-line treatments is needed.

A multivariate study of predictors of repeat parasuicide

OBJECTIVE

To identify variables which differentiate future repeaters of parasuicide from non-repeaters in a multivariate analysis.

METHOD

Interviews were conducted with 507 parasuicide cases; data were collected on precipitating factors for the index parasuicide, psychiatric and medical history, stressful life events, prior history of parasuicide, hopelessness, anger, self-esteem and social adjustment. Individuals were followed for 1-2 years to determine if a repeat parasuicide occurred.

RESULTS

A logistic regression model identified four significant predictors of repeat parasuicide: prior history of parasuicide, a history of depression, a history of schizophrenia and poor physical health. A risk factor scale constructed from these four variables showed that the risk of repeat parasuicide increases as the number of risk factors increases.

CONCLUSION

This study identifies four key predictors of repeat parasuicide, and provides evidence that the risk of repeat parasuicide increases when multiple risk factors are present.

Underreporting of vertebral fractures on routine chest radiography

OBJECTIVE

Osteoporosis is underdiagnosed and therefore undertreated. We determined the potential usefulness of chest radiography for detecting clinically important vertebral fractures by performing semiquantitative reviews and quantitative digital morphometry on 100 routine chest radiographs taken in the emergency department and comparing the yield of these independent reviews with official radiology reports.

MATERIALS AND METHODS

One hundred randomly selected chest radiographs of patients 60 years or older who presented to the emergency department of a tertiary care hospital were evaluated. Radiographs were selected without knowledge of the presenting complaint and were independently reviewed by two board-certified radiologists and a radiology resident. A validated semiquantitative method was used to assess lateral chest radiographs for vertebral fracture. In addition, quantitative digital morphometry was undertaken. A clinically important vertebral fracture was defined as one that was at least moderate to severe (loss of height >or=> 25%).

RESULTS

Mean age of the population was 75 years, 47% were women, and 46% were admitted to the hospital. According to the reference radiologist, prevalence of moderate to severe vertebral fractures was 22%. Simple agreement was 87-88% among reviewers; kappa values were moderate (0.56-0.58). The greatest agreement was between the reference standard radiologist and quantitative digital morphometry (89% agreement; kappa = 0.67). Only 55% (12/22) of vertebral fractures we identified were mentioned in the official radiology reports.

CONCLUSION

Chest radiography has potential as a screening tool for revealing previously undiagnosed vertebral fractures, although in this study only half of moderate to severe fractures that we identified were mentioned in official reports.

Utilization of the emergency department after self-inflicted injury

OBJECTIVES

To compare emergency department (ED) utilization by individuals who present with self-inflicted injuries with utilization by control populations. Individuals with self-inflicted injuries commonly present to the ED, yet little research has been conducted on this population in this setting.

METHODS

Individuals who had an ED presentation in 1995-1996 for a self-inflicted injury were tracked prospectively for three to four years of follow-up. This group was matched by age and gender to two groups: individuals who presented with asthma and individuals who presented with other complaints. Data on return visits to the ED were collected from an administrative database. Groups were compared on rates of return visits.

RESULTS

There were 478 individuals randomly selected for each group. Individuals in the self-inflicted injury group had higher rates of return visits to the ED over the follow-up period: 232.7 visits per 100 person-years for the self-inflicted injury group, compared with 117.6 for the asthma group, and 83.0 for the "other" group (p < 0.001). The self-inflicted injury group had higher rates for many types of diagnoses: self-inflicted injuries, mental disorders, substance abuse, unintentional injuries, assault, headache pain, and other complaints (all p < 0.001). Patients with more than three repeat visits per year were more common in the self-inflicted injury group (20.1%) than the asthma or "other" groups (9.2% and 5.6%, respectively).

CONCLUSIONS

Individuals who harm themselves are chronic users of the ED. The ED represents an opportune setting from which individuals can be directed to appropriate treatment programs.

Gambling decisions: an early intervention program for problem gamblers

An implementation and one-year follow-up of the Gambling Decisions program attempted to answer several important questions. First, is controlled gambling a viable treatment option for some gamblers? Can earlier stage problem gamblers be separated for treatment from those with more severe problems? Finally, would problem gamblers utilize a community health agency for treatment of their excessive gambling? A pretest/posttest design was chosen where the efficacy of the program was assessed using repeated measures ANOVA analysis. Results showed that an average loss of $608 over a 4-week period was reduced to $113 immediately after the 6-week program and to a loss of $73 at 12 months. The average number of hours spent gambling per 4 weeks was significantly reduced from 23.5 at pretest to 6.5 at the 12 month posttest. Significant decreases were also observed in the number of days per week that clients gambled, and clients reported significant reductions in everyday life problems related to gambling after completing the program.