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Zhao YJ, Lim JYX, Wong PS. Diagnosis and Management of Headaches in the Emergency Department (ED) in Adults and Children. Neurol India 2021; 69:S173-S182. [PMID: 34003163 DOI: 10.4103/0028-3886.315977] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Background Headache accounts for a significant number of cases presenting to the Emergency Department (ED) and has a high societal cost, contributed by recurrent ED and clinic visits, and unnecessary diagnostic tests. Objective This review article covers the important clinical tools needed to evaluate headaches in both adults and children in the ED. Methods Medline/PubMed was searched using the keywords "Emergency department", "headache", "adult", "pediatric", "clinical assessment", "diagnosis" and "treatment", in the title or abstract. The search covers the period from 1 January 1990 to 31 December 2019. Results The articles selected were based on their relevancy to the objective of this review article. Additional relevant publications were identified from article references lists. Conclusion The emergency physician plays a key role in differentiating between primary and secondary headaches. Within the limited ED resources, appropriate diagnostic testing should be used to identify the life-threatening headaches. This will ensure patients are given the appropriate evidence-based pharmacological therapy and holistic management.
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Affiliation(s)
- Yi J Zhao
- Department of Neurology, National Neuroscience Institute -SGH Campus, Singapore
| | - Jocelyn Y X Lim
- KK Women and Children's Hospital, Neurology Service, Singapore
| | - Pei S Wong
- SGH Department of Pharmacy, NUS Dept of Pharmacy, Singapore
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Zitek T, Sigal T, Sun G, Martin Manuel C, Tran K. I-FiBH trial: intravenous fluids in benign headaches-a randomised, single-blinded clinical trial. Emerg Med J 2020; 37:469-473. [PMID: 32620543 DOI: 10.1136/emermed-2019-209389] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Revised: 05/21/2020] [Accepted: 05/25/2020] [Indexed: 01/03/2023]
Abstract
BACKGROUND Many emergency physicians use an intravenous fluid bolus as part of a 'cocktail' of therapies for patients with headache, but it is unclear if this is beneficial. The objective of this study was to determine if an intravenous fluid bolus helps reduce pain or improve other outcomes in patients who present to the ED with a benign headache. METHODS This was a randomised, single-blinded, clinical trial performed on patients aged 10-65 years old with benign headaches who presented to a single ED in Las Vegas, Nevada, from May 2017 to February 2019. All patients received prochlorperazine and diphenhydramine, and they were randomised to also receive either 20 mL/kg up to 1000 mL of normal saline (the fluid bolus group) or 5 mL of normal saline (the control group). The primary outcome was the difference between groups in mean pain reduction 60 min after the initiation of treatment. Secondarily, we compared groups with regards to pain reduction at 30 min, nausea scores, the use of rescue medications and disposition. RESULTS We screened 67 patients for enrolment, and 58 consented. Of those, 35 were randomised to the fluid bolus group and 23 to the control group. The mean pain score dropped by 48.3 mm over 60 min in the fluid bolus group, compared with 48.7 mm in the control group. The between groups difference of 0.4 mm (95% CI -16.5 to 17.3) was not statistically significant (p=0.96). Additionally, no statistically significant difference was found between groups for any secondary outcome. CONCLUSION Though our study lacked statistical power to detect small but clinically significant differences, ED patients who received an intravenous fluid bolus for their headache had similar improvements in pain and other outcomes compared with those who did not. TRIAL REGISTRATION NUMBER NCT03185130.
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Affiliation(s)
- Tony Zitek
- Department of Emergency Medicine, Kendall Regional Medical Center, Miami, Florida, USA
| | - Tiffany Sigal
- Department of Emergency Medicine, Mike O'Callaghan Federal Medical Center, Nellis Afb, Nevada, USA
| | - Gina Sun
- Department of Emergency Medicine, University of Nevada, Las Vegas School of Medicine, Las Vegas, Nevada, USA
| | - Chris Martin Manuel
- Department of Emergency Medicine, University Medical Center of Southern Nevada, Las Vegas, Nevada, USA
| | - Khanhha Tran
- Department of Emergency Medicine, University Medical Center of Southern Nevada, Las Vegas, Nevada, USA
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Jarvis JL, Johnson B, Crowe RP. Out-of-hospital assessment and treatment of adults with atraumatic headache. J Am Coll Emerg Physicians Open 2020; 1:17-23. [PMID: 33000009 PMCID: PMC7493518 DOI: 10.1002/emp2.12006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2019] [Revised: 11/08/2019] [Accepted: 11/25/2019] [Indexed: 11/06/2022] Open
Abstract
OBJECTIVE Little is known about the presentation or management of patients with headache in the out-of-hospital setting. Our primary objective is to describe the out-of-hospital assessment and treatment of adults with benign headache. We also describe meaningful pain reduction stratified by commonly administered medications. METHODS This retrospective evaluation was conducted using data from a large national cohort. We included all 911 responses by paramedics for patients 18 and older with headache. We excluded patients with trauma, fever, suspected alcohol/drug use, or who received medications suggestive of an alternate condition. We presented our findings with descriptive statistics. RESULTS Of the 5,977,612 emergency responses, 1.1% (66,235) had a provider-documented primary impression of headache or migraine and 52.5% (34,763) met inclusion criteria. An initial pain score was recorded for 73.5% (25,544) of patients, and 58.5% (14,948) of these patients had multiple pain scores documented. Of the patients with multiple pain scores documented, 53.8% (8037) of patients had an initial pain score >5. Of these, 7.1% (573) were administered any medication. Among patients receiving a single medication, Fentanyl was the most commonly administered (32.1%, 126). As a group, opioids were the most commonly administered class of drugs (38.9%, 153) and were associated with the largest proportion of clinically significant pain reduction (69.3%, 106). Dopamine antagonists were given least frequently (9.9%, 39) but had the second largest proportion of pain reduction (43.6%, 17). CONCLUSION Out-of-hospital pain scores were documented infrequently and less than one in five patients with initial pain scores >5 received medication. Additionally, adherence to evidence-based guidelines was infrequent.
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Affiliation(s)
- Jeffrey L. Jarvis
- Williamson County EMSGeorgetownTexasUSA
- Department of Emergency MedicineBaylor Scott & White HealthcareTempleTexasUSA
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Golikhatir I, Cheraghmakani H, Bozorgi F, Jahanian F, Sazgar M, Montazer SH. The Efficacy and Safety of Prochlorperazine in Patients With Acute Migraine: A Systematic Review and Meta-Analysis. Headache 2019; 59:682-700. [PMID: 30990883 DOI: 10.1111/head.13527] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/14/2019] [Indexed: 12/17/2022]
Abstract
OBJECTIVE The aim of this review was to evaluate the efficacy and safety of prochlorperazine (PCP) in patients with acute migraine headache in the emergency department (ED). METHODS Electronic databases (Medline, Scopus, Web of Science, and Cochrane) were searched for randomized clinical trials that investigated the effect of PCP on headache relief. The outcomes were the number of patients without headache or with reduced headache severity, the number of adverse events, and the need for rescue analgesia. RESULTS From 450 citations, 11 studies (n = 771) with 15 comparison arms met the inclusion criteria. Overall, PCP was more effective than placebo (OR = 7.23; 95% CI = 3.82-3.68), metoclopramide (OR = 2.89; 95% CI = 1.42-5.86), and other active comparators (OR = 3.70; 95% CI = 2.41-5.67) for headache relief. The odds ratio of experiencing adverse events with PCP compared with placebo was 5.79 (95% CI = 2.43-13.79). When PCP compared with other active comparators, no statistical difference was found regarding the overall number of adverse events (OR = 1.88; 95% CI = 0.99-3.59). However, PCP significantly increased the odds of akathisia/dystonia (OR = 2.55; 95% CI = 1.03-6.31). The request for rescue analgesia was significantly lower in the PCP group compared with other groups (16% vs 84%; OR = 0.16; 95% CI = 0.09-27). CONCLUSIONS For adult patients with acute migraine, PCP could effectively abort the acute attack and reduce the request for rescue analgesia in the ED. However, compared with placebo, PCP could increase the risk of adverse events.
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Affiliation(s)
- Iraj Golikhatir
- Department of Emergency Medicine, Diabetes Research Center, Faculty of Medicine, Mazandaran University of Medical Sciences, Sari, Iran
| | - Hamed Cheraghmakani
- Department of Neurology, Faculty of Medicine, Mazandaran University of Medical Sciences, Sari, Iran
| | - Farzad Bozorgi
- Department of Emergency Medicine, Gut and Liver Research Center, Faculty of Medicine, Mazandaran University of Medical Sciences, Sari, Iran
| | - Fatemeh Jahanian
- Department of Emergency Medicine, Faculty of Medicine, Mazandaran University of Medical Sciences, Sari, Iran
| | - Mohammad Sazgar
- Department of Emergency Medicine, Faculty of Medicine, Mazandaran University of Medical Sciences, Sari, Iran
| | - Seyed Hosein Montazer
- Department of Emergency Medicine, Orthopedic Research Center, Faculty of Medicine, Mazandaran University of Medical Sciences, Sari, Iran
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Rashed A, Mazer-Amirshahi M, Pourmand A. Current Approach to Undifferentiated Headache Management in the Emergency Department. Curr Pain Headache Rep 2019; 23:26. [PMID: 30868276 DOI: 10.1007/s11916-019-0765-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
PURPOSE OF REVIEW To discuss pharmacological interventions in the emergency department (ED) setting for the management of acute primary headache. RECENT FINDINGS Acute headache treatment in the ED has seen an expansion in terms of possible pharmacological interventions in recent years. After a thorough evaluation ruling out dangerous causes of headache, providers should take the patient's history, comorbidities, and prior therapy into consideration. Antidopaminergics have an established role in the management of acute, severe, headache with manageable side-effect profiles. However, recent studies suggest anesthetic and anti-epileptic drugs may play roles in headache treatment in the ED. Current literature also suggest steroids as a promising tool for emergency department clinicians combating the readmission of patients with recurrent headaches. Emergency medicine providers must be cognizant of these traditional and emerging therapies in order to optimize the care of headache patients.
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Affiliation(s)
- Amir Rashed
- Department of Emergency Medicine, George Washington University School of Medicine and Health Sciences, 2120 L St., Washington, DC, 20037, USA
| | - Maryann Mazer-Amirshahi
- Department of Emergency Medicine, MedStar Washington Hospital Center, Washington, DC, USA.,School of Medicine, Georgetown University, Washington, DC, USA
| | - Ali Pourmand
- Department of Emergency Medicine, George Washington University School of Medicine and Health Sciences, 2120 L St., Washington, DC, 20037, USA.
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Sokolov AY, Popova NS, Povarenkov AS, Amelin AV. The Role of Dopamine in Primary Headaches. NEUROCHEM J+ 2018. [DOI: 10.1134/s1819712418030145] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
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A Comparison of Headache Treatment in the Emergency Department: Prochlorperazine Versus Ketamine. Ann Emerg Med 2017; 71:369-377.e1. [PMID: 29033296 DOI: 10.1016/j.annemergmed.2017.08.063] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2017] [Revised: 07/08/2017] [Accepted: 08/24/2017] [Indexed: 11/23/2022]
Abstract
STUDY OBJECTIVE Intravenous subdissociative-dose ketamine has been shown to be effective for pain management, but has not been specifically studied for headaches in the emergency department (ED). For this reason, we designed a study to compare standard treatment (prochlorperazine) with ketamine in patients with benign headaches in the ED. METHODS This study was a multicenter, double-blind, randomized, controlled trial with a convenience sample of patients presenting to the ED with benign headaches. Patients were randomized to receive either prochlorperazine and diphenhydramine or ketamine and ondansetron. Patients' headache severity was measured on a 100-mm visual analog scale (VAS) at 0, 15, 30, 45, and 60 minutes. Nausea, vomiting, anxiety, and the need for rescue medications were also tracked. Patients were contacted at 24 to 48 hours posttreatment to rate their satisfaction and to determine whether they were still experiencing a headache. RESULTS There were a total of 54 subjects enrolled. Two patients in the ketamine group and one in the prochlorperazine group withdrew because of adverse effects of the medications. In regard to the primary outcome, at 60 minutes, the prochlorperazine group had a mean improvement in VAS pain scores of 63.5 mm compared with 43.5 mm in the ketamine group, corresponding to a between-groups difference of 20.0 mm (95% confidence interval [CI] 2.8 to 37.2 mm) and a P value of .026. At 45 minutes, the prochlorperazine group had a mean improvement in pain scores of 56.1 mm compared with 38.0 mm in the ketamine group, a difference of 18.1 mm (95% CI 1.0 to 35.2 mm). At 24- to 48-hour follow-up, the mean satisfaction score was 8.3 of 10 for prochlorperazine and 4.9 of 10 for ketamine, a difference of 3.4 (95% CI 1.2 to 5.6). There was not a statistically significant difference in the percentage of patients who had a headache at follow-up or in other secondary outcomes. CONCLUSION Prochlorperazine appears to be superior to ketamine for the treatment of benign headaches in the ED.
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Gaffigan ME, Bruner DI, Wason C, Pritchard A, Frumkin K. A Randomized Controlled Trial of Intravenous Haloperidol vs. Intravenous Metoclopramide for Acute Migraine Therapy in the Emergency Department. J Emerg Med 2015; 49:326-34. [DOI: 10.1016/j.jemermed.2015.03.023] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2014] [Revised: 03/09/2015] [Accepted: 03/24/2015] [Indexed: 12/26/2022]
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Anxiolytic medication as an adjunct to morphine analgesia for acute low back pain management in the emergency department: a prospective randomized trial. Spine (Phila Pa 1976) 2014; 39:17-22. [PMID: 24270933 DOI: 10.1097/brs.0000000000000038] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Prospective, single-blinded, and randomized clinical trial. OBJECTIVE This study evaluates the added benefit of promethazine administration as an anxiolytic adjunct to morphine analgesia in reducing acute low back pain (LBP) compared with morphine alone. SUMMARY OF BACKGROUND DATA Acute LBP is one of the most common reasons for emergency department (ED) visits. The optimal analgesic treatment for acute LBP remains controversial. Anxiety relief has been shown to improve pain management in the ED setting. We hypothesized that administration of the antihistamine promethazine as an anxiolytic adjunct to morphine analgesia will improve LBP management compared with morphine alone. METHODS Fifty-nine adults, who were treated in our ED for severe acute LBP (visual analogue scale ≥ 70 mm), were randomly enrolled in the study. Thirty patients received slow infusion of intravenous (IV) morphine 0.1 mg/kg in normal saline and 29 patients received an analgesic regimen of IV morphine 0.1 mg/kg with promethazine 25 mg administered similarly. Pain and anxiety levels were subjectively assessed by the patients on a 100-mm visual analogue scale before and after treatment. Adverse event related to analgesia were recorded in real time. RESULTS After analgesia administration patients' pain rating decreased by 43 mm in the morphine group and by 39 mm in the morphine/promethazine group (P = 0.26). Similarly, patients' anxiety decreased by 19 mm in the morphine group and by 13 mm in the morphine/promethazine group (P = 0.37). The average ED stay was 78 minutes longer in the morphine/promethazine group (P = 0.01), due to the strong sedative effect of promethazine. Patients' satisfaction and the rate of adverse events were similar in both groups. CONCLUSION IV administration of morphine-promethazine regimen for pain and anxiety relief associated with acute LBP showed no advantage compared with IV morphine alone and significantly lengthened the overall ED stay. Thus, we think that promethazine has no place in acute LBP management in the adult ED setting. LEVEL OF EVIDENCE 1.
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Leung S, Bulloch B, Young C, Yonker M, Hostetler M. Effectiveness of standardized combination therapy for migraine treatment in the pediatric emergency department. Headache 2013; 53:491-197. [PMID: 23406529 DOI: 10.1111/head.12042] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/04/2012] [Indexed: 12/24/2022]
Abstract
OBJECTIVE To compare outcomes of pediatric migraine patients treated in an emergency department (ED) before and after implementation of a standardized combination intravenous therapy regimen aimed toward improving and standardizing abortive migraine therapy. BACKGROUND In a pediatric ED, migraines represent 8-18% of all headache visits. Despite this large number, no standard treatment for acute migraine therapy currently exists. METHODS The study utilized a retrospective chart review of patients seeking acute migraine treatment at a tertiary care, pediatric ED from August 2006 to March 2010. Inclusion criteria were pediatric migraine patients as defined by International Headache Society guidelines. The comparison population received various migraine therapies based on attending practice preference. After October 2008, patients received standardized intravenous combination therapy involving a normal saline fluid bolus, ketorolac, prochlorperazine, and diphenhydramine. Occasionally, metoclopramide was substituted during prochlorperazine shortages. Reduction in headache pain score was the primary outcome. Secondary outcome measures included length of ED stay, hospital admission rate, and ED readmission rate within 48 hours. RESULTS The study yielded 87 patients who received standardized combination therapy and 165 comparison patients. No significant difference in patient characteristics existed when evaluating patient demographics, outpatient medication use, and initial headache pain score. When compared with the non-standardized therapy population, the combination therapy patients revealed significant reductions in pain score (decrease of 5.3 vs. 6.9, difference -1.6, 95% confidence interval -2.2 to -0.8, P < .001), length of ED stay (5.3 vs. 4.4 hours, difference 0.9, 95% confidence interval 0.2-1.6, P = .008), and hospital admission rate (32% vs. 3%, P < .001) without changes in ED return rate (7% vs. 2%, P = .148). CONCLUSION Standardized combination therapy is effective for acute pediatric migraine therapy in the ED by significantly reducing headache pain scores, length of ED stay, and hospital admission rates.
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Kelley NE, Tepper DE. Rescue therapy for acute migraine, part 2: neuroleptics, antihistamines, and others. Headache 2012; 52:292-306. [PMID: 22309235 DOI: 10.1111/j.1526-4610.2011.02070.x] [Citation(s) in RCA: 65] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVES This second portion of a 3-part series examines the relative effectiveness of headache treatment with neuroleptics, antihistamines, serotonin antagonists, valproate, and other drugs (octreotide, lidocaine, nitrous oxide, propofol, and bupivacaine) in the setting of an emergency department, urgent care center, or headache clinic. METHODS MEDLINE was searched using the terms "migraine" AND "emergency" AND "therapy" OR "treatment." Reports were from emergency department and urgent care settings and involved all routes of medication delivery. Reports from headache clinics were only included if medications were delivered by a parenteral route. RESULTS Prochlorperazine, promethazine, and metoclopramide, when used alone, were superior to placebo. Droperidol and prochlorperazine were superior or equal in efficacy to all other treatments, although they also have more side effects (especially akathisia). Metoclopramide was equivalent to prochlorperazine and, when combined with diphenhydramine, was superior in efficacy to triptans and non-steroidal anti-inflammatory drugs. Meperidine was inferior to chlorpromazine and equivalent to the other neuroleptics. The overall percentage of patients with pain relief after taking droperidol and prochlorperazine was equivalent to sumatriptan. CONCLUSIONS Prochlorperazine and metoclopramide are the most frequently studied of the anti-migraine medications in the emergent setting, and the effectiveness of each is superior to placebo. Prochlorperazine is superior or equivalent to all other classes of medications in producing migraine pain relief. Dopamine antagonists, in general, appear to be equivalent for migraine pain relief to the migraine-"specific" medications sumatriptan and dihydroergotamine, although there are fewer studies involving the last two. Lack of comparisons to placebo and the frequent use of combination medications in treatment arms complicate the comparison of single agents to one other.
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Affiliation(s)
- Nancy E Kelley
- Center for Headache and Pain, Neurological Institute, Cleveland Clinic, Cleveland, OH 44195, USA
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Faine B, Hogrefe C. News Flash: Old Mother Hubbard Reports the Cupboard is Bare… Time for the FDA to Let Droperidol Out of the (Black) Box. Ann Pharmacother 2012; 46:1259-61. [DOI: 10.1345/aph.1r156] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
A quick way for a clinical pharmacist to eliminate himself or herself from “employee of the month” consideration is to mention the term medication shortage. Even with training geared toward maximizing resources, the cumulative disappearance of a plethora of medications for the treatment of nausea, vomiting, and/or primary headaches is almost too much for emergency medicine physicians to manage. With prochlorperazine, metoclopramide, promethazine, and ondansetron in increasingly short supply, it is time for the Food and Drug Administration to revisit droperidol's black box warning driven by Q Tc interval prolongation, given its questionable validity, and restore droperidol's place in the armamentarium of emergency medicine physicians.
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Affiliation(s)
- Brett Faine
- Brett Faine PharmD, Emergency Medicine Clinical Pharmacy Specialist, Department of Pharmaceutical Care and Department of Emergency Medicine, University of Iowa Hospitals and Clinics, Iowa City
| | - Christopher Hogrefe
- Christopher Hogrefe MD, Visiting Associate Fellow, Department of Emergency Medicine, University of Iowa Hospitals and Clinics
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Seidel S, Aigner M, Ossege M, Pernicka E, Wildner B, Sycha T. Antipsychotics for acute and chronic pain in adults. J Pain Symptom Manage 2010; 39:768-78. [PMID: 20226624 DOI: 10.1016/j.jpainsymman.2009.09.008] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2009] [Revised: 09/07/2009] [Accepted: 09/28/2009] [Indexed: 10/19/2022]
Abstract
CONTEXT The role of antipsychotics as adjuvant analgesics is a subject of long-standing controversy. Antipsychotics have been used to treat chronic pain (e.g., chronic headache, fibromyalgia, and painful diabetic neuropathy). With atypical antipsychotics, a new class of antipsychotics, with fewer extrapyramidal side effects and additional benefits, may be available. OBJECTIVES This review aimed to assess analgesic efficacy and adverse effects of antipsychotics in acute or chronic pain. METHODS Randomized controlled trials of adults prescribed any dose of oral antipsychotics for acute or chronic pain, describing subjective pain assessment as either the primary or a secondary outcome, were included in this review. RESULTS We included 11 studies involving a total number of 770 participants. Data from five randomized, double-blind studies showed beneficial effects of antipsychotics in the treatment of acute and chronic pain. Because of the clinical heterogeneity of painful conditions studied and significant statistical heterogeneity, the intended meta-analysis was omitted. The most frequently reported adverse effects were extrapyramidal (i.e., involuntary movements, parkinsonism, and akathisia) and sedating effects. CONCLUSION Because of limitations in the available evidence, further research is needed to understand whether antipsychotics are effective for acute or chronic pain or specific pain conditions.
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Affiliation(s)
- Stefan Seidel
- Department of Neurology, Medical University of Vienna, Vienna, Austria.
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Abstract
Headache is the fifth most common primary complaint of patients presenting to an emergency department (ED) in the United States. The emergency physician (EP) plays a unique role in the management of these patients, one that differs from that of the primary care physician, the neurologist, and other specialists. Diagnostic nomenclature used in the ED is necessarily less specific, as care is more appropriately focused on the relief of symptoms and the identification of life-threatening causes. By seeking a limited number of specific critical features on history and physical examination, the EP can minimize the risk of overlooking one of these dangerous causes of headache. When certain features are present, empirical therapies and diagnostic testing should be initiated in the ED. The most frequently encountered pitfalls in the management of patients with headache in emergency medicine practice, and those with the greatest likelihood to adversely affect patient outcomes, are discussed.
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Kostic MA, Gutierrez FJ, Rieg TS, Moore TS, Gendron RT. A prospective, randomized trial of intravenous prochlorperazine versus subcutaneous sumatriptan in acute migraine therapy in the emergency department. Ann Emerg Med 2010; 56:1-6. [PMID: 20045576 DOI: 10.1016/j.annemergmed.2009.11.020] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2008] [Revised: 11/04/2009] [Accepted: 11/19/2009] [Indexed: 11/27/2022]
Abstract
STUDY OBJECTIVE Intravenous (IV) prochlorperazine with diphenhydramine is superior to subcutaneous sumatriptan in the treatment of migraine patients presenting to the emergency department (ED). METHODS In this randomized, double-blind, placebo-controlled trial, after providing written informed consent, patients presenting to the ED with a chief complaint of migraine received a 500-mL bolus of IV saline solution and either 10 mg prochlorperazine with 12.5 mg diphenhydramine IV plus saline solution placebo subcutaneously or saline solution placebo IV plus 6 mg sumatriptan subcutaneously. Pain intensity was assessed with 100-mm visual analog scales (visual analog scale at baseline and every 20 minutes for 80 minutes). The primary outcome was change in pain intensity from baseline to 80 minutes or time of ED discharge if subjects remained in the ED for fewer than 80 minutes after treatment. Sedation and nausea were assessed every 20 minutes with visual analog scale scales, and subjects were contacted within 72 hours to assess headache recurrence. RESULTS Sixty-eight subjects entered the trial, with complete data for 66 subjects. Baseline pain scores were similar for the prochlorperazine/diphenhydramine and sumatriptan groups (76 versus 71 mm). Mean reductions in pain intensity at 80 minutes or time of ED discharge were 73 mm for the prochlorperazine/diphenhydramine group and 50 mm for those receiving sumatriptan (mean difference 23 mm; 95% confidence interval 11 to 36 mm). Sedation, nausea, and headache recurrence rates were similar. CONCLUSION IV prochlorperazine with diphenhydramine is superior to subcutaneous sumatriptan in the treatment of migraine.
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Affiliation(s)
- Mark A Kostic
- Department of Emergency Medicine, Naval Medical Center, Portsmouth, VA, USA.
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Kelly AM, Walcynski T, Gunn B. The Relative Efficacy of Phenothiazines for the Treatment of Acute Migraine: A Meta-Analysis. Headache 2009; 49:1324-32. [DOI: 10.1111/j.1526-4610.2009.01465.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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