Intra-venous chlorpromazine with fluid treatment in status migrainosus

Clinical characteristics and treatment of patients hospitalized with status migrainosus: a retrospective analysis

BACKGROUNDS

Status Migrainosus is not rare, but there is still very little research data on this aspect, and treatment and diagnosis face huge challenges.

OBJECTS

The purpose of this study was to characterize the clinical characteristics and current treatment status of status migrainosus patients hospitalized in the Department of Neurology.

METHODS

This retrospective study examined patients with status migrainosus who were hospitalized in the Department of Neurology at a tertiary hospital in Chengdu, China, from August 1, 2015, to July 31, 2024. This study analyzed the demographic characteristics, clinical features, and treatment approaches of these status migrainosus patients.

RESULTS

Among the 1,237 patients hospitalized with a primary complaint of headache, 26 were ultimately diagnosed with status migrainosus. Of these status migrainosus patients, 21 patients with complete information were analyzed. The cohort predominantly consisted of middle-aged women, with most reporting moderate to severe headache intensity. The most common triggers identified were lack of sleep (66.7%) and mood disorders (42.8%). The average duration of status migrainosus was 9.3 days. In terms of treatment, NSAIDs were the most frequently administered (95.2%). During hospitalization, the most commonly used oral analgesics were NSAIDs and triptans, while intravenous treatments primarily included dexamethasone and valproic acid. 87.5% (14 out of 16) of the patients received preventive migraine treatment following discharge.

CONCLUSION

The clinical characteristics of Status Migrainosus are generally similar to those of episodic migraine. Treatment to terminate the headache attack often requires the combined use of multiple drugs.

Real-world approaches to outpatient treatment of status migrainosus: A survey study

OBJECTIVES

Identify how the American Headache Society (AHS) membership manages status migrainosus (SM) among outpatients.

BACKGROUND

SM is defined as a debilitating migraine attack lasting more than 72 h. There is no standard of care for SM, including whether a 72-h duration is required before the attack can be treated as SM.

METHODS

The Refractory Headache Special Interest Group from AHS developed a four-question survey distributed to AHS members enquiring (1) whether they treat severe refractory migraine attacks the same as SM regardless of duration, (2) what their first step in SM management is, (3) what the top three medications they use for SM are, and (4) whether they are United Council for Neurologic Subspecialties (UCNS) certified. The survey was conducted in January 2022. Descriptive statistical analyses were performed.

RESULTS

Responses were received from 196 of 1859 (10.5%) AHS members; 64.3% were UCNS certified in headache management. Respondents treated 69.4% (136/196) of patients with a severe refractory migraine attack as SM before the 72-h period had elapsed. Most (76.0%, 149/196) chose "treat remotely using outpatient medications at home" as the first step, 11.2% (22/196) preferred procedures, 6.1% (12/196) favored an infusion center, 6.1% (12/196) sent patients to the emergency department (ED) or urgent care, and 0.5% (1/196) preferred direct hospital admission. The top five preferred medications were as follows: (1) corticosteroids (71.4%, 140/196), (2) nonsteroidal anti-inflammatory drugs (NSAIDs) (50.1%, 99/196), (3) neuroleptics (46.9%, 92/196), (4) triptans (30.6%, 60/196), and (5) dihydroergotamine (DHE) (21.4%, 42/196).

CONCLUSIONS

Healthcare professionals with expertise in headache medicine typically treated severe migraine attacks early and did not wait 72 h to fulfill the diagnostic criteria for SM. Outpatient management with one or more medications for home use was preferred by most respondents; few opted for ED referrals. Finally, corticosteroids, NSAIDs, neuroleptics, triptans, and DHE were the top five preferred treatments for home SM management.

Intravenous Chlorpromazine as Potentially Useful Treatment for Chronic Headache Disorders

OBJECTIVE

The aim of this study was to describe a group of patients with chronic headache disorders (CH) and medication overuse headache (MOH) treated with intravenous chlorpromazine (IVC). We hypothesized that IVC is an effective and safe addition to well-known treatment strategies for CH and MOH management.

INTRODUCTION

Up to 4% of the general population could experience CH. Most cases occur in women, in association with MOH. To date, evidence to support different treatment strategies is lacking. Although IVC is frequently used in the emergency room (ER), documentation on its use as supportive treatment for CH and for withdrawal management of MOH is poor.

METHODS

A retrospective cohort of patients hospitalized to receive treatment for CH in a specialized neurological center in Argentina was analyzed.

RESULTS

A total of 35 CH patients were included. Of the 35 patients, 33 (94%) patients also presented MOH. Patients reported only minor side effects to IVC administration (mainly drowsiness and symptomatic hypotension). Three months after inpatient treatment, the number of ER visits made by these patients decreased from an average of 2.8 in the 3 months prior to hospitalization to 0.7 after it (72%, P = .009). Headache frequency decreased in 20/34 (59%) patients during the same time period. Pain levels had dropped from a mean of 8 points at admission (in the scale of 1-10) to 2 points at discharge. In the first 3 months of follow-up, the average number of days per month in which patients experienced headache decreased from 28.9 to 15.4 days (53.3%, P < .0001).

CONCLUSION

In this particular group of inpatients, there were no significant safety issues with IVC administration and the study might suggest that the efficacy of IVC as an add-on treatment for CH and MOH.

A Nonopioid, Nonbenzodiazepine Treatment Approach for Intractable Nausea and Vomiting in the Emergency Department

GOAL

We sought to assess the feasibility and efficacy of a treatment protocol for nausea and vomiting using the combination of chlorpromazine, a dopamine antagonist antiemetic, and ketamine, a nonopioid analgesic.

BACKGROUND

Increasing numbers of patients with cannabis use disorder are presenting to emergency departments with a poorly understood syndrome characterized by intractable nausea and vomiting.

METHODS

This is a prospective, observational study involving a convenience sample of patients with unexplained nausea and vomiting. Subjects were given ketamine 15 mg slow intravenous push and chlorpromazine 12.5 mg intravenous over 15 minutes. Outcomes were number of episodes of emesis after study drug administration; change in nausea severity; change in pain severity; adverse events; and patient satisfaction.

RESULTS

We enrolled 28 subjects on 30 emergency department visits. Twenty-three subjects (82%) reported at least weekly cannabis use with 19 reporting daily use. Initial symptoms were severe, with median pain and nausea scores both 10. After receiving study medication, the mean decrease in pain score over 120 minutes was 4.1 (95% confidence interval: 3.2, 5.0) and the mean decrease in nausea score was 4.9 (95% confidence interval: 4.0, 5.8). There were no adverse events. All 28 subjects who were asked reported they would want to receive these medications again.

CONCLUSION

In this single-center study, the majority of patients presenting with intractable nausea and vomiting reported heavy cannabis use, and symptoms were severe. The combination of chlorpromazine plus ketamine resulted in rapid, definitive cessation of symptoms in most of these patients without the need for opioids or benzodiazepines.

Emergency Department and Inpatient Management of Headache in Adults

PURPOSE OF REVIEW

This article reviews treatment options for patients presenting with headache in the emergency department (ED) and for inpatients, including red flags and status migrainosus (SM).

RECENT FINDINGS

Most patients presenting with headache in the ED will have migraine, but red flags must be reviewed to rule out secondary headaches. SM refractory to home treatment is a common reason for ED presentation or inpatient admission, but high-quality treatment evidence is lacking. Common treatments include intravenous fluids, anti-dopaminergic agents with diphenhydramine, steroids, divalproex, nonsteroidal anti-inflammatory drugs, intravenous dihydroergotamine, and nerve blocks. Other therapies (e.g., ketamine and lidocaine) are used with limited or inconsistent evidence. There is evidence for inpatient behavioral management therapy. This article details red flags to review in the workup of headache presentation in the ED and provides a step-wise approach to ED and inpatient management. However, more studies are needed to better optimize care.

Effectiveness of intravenous dexamethasone, metoclopramide, ketorolac, and chlorpromazine for pain relief and prevention of recurrence in the migraine headache: a prospective double-blind randomized clinical trial

Dexamethasone, metoclopramide, ketorolac, and chlorpromazine have been used for the treatment of migraine headache. However, the effectiveness of these drugs in pain relief and prevention of recurrence and their side effects have not been compared yet. This was a randomized, double-blind clinical trial. Subjects were randomized to four groups; each received one of the following drugs intravenously: dexamethasone 8 mg, ketorolac 30 mg, metoclopramide 10 mg, and chlorpromazine 25 mg. The severity of headache in the two groups was assessed at starting point, 1 h and 24 h after the administration of drug using the visual analogue scale (VAS) on a scale of 0 to 10. No significant difference was found in the severity of symptoms between the four study groups before treatment, 1 h, and 24 h after treatment. The effect of all mentioned drugs on acute migraine headache was statistically significant at 1 and 24 h post-treatment compared to baseline. No significant difference was detected in the number of unresponsive cases between the four groups. There was a trend toward higher effectiveness of dexamethasone in prevention of recurrence (P = 0.05). Side effects were more common in chlorpromazine and less common in the dexamethasone-treated patients (P < 0.001). The present clinical trial shows the effectiveness of dexamethasone in prevention of recurrence and low frequency of treatment side effects.