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Karsan N, Goadsby PJ. Intervening in the Premonitory Phase to Prevent Migraine: Prospects for Pharmacotherapy. CNS Drugs 2024; 38:533-546. [PMID: 38822165 DOI: 10.1007/s40263-024-01091-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/15/2024] [Indexed: 06/02/2024]
Abstract
Migraine is a common brain condition characterised by disabling attacks of headache with sensory sensitivities. Despite increasing understanding of migraine neurobiology and the impacts of this on therapeutic developments, there remains a need for treatment options for patients underserved by currently available therapies. The first specific drugs developed to treat migraine acutely, the serotonin-5-hydroxytryptamine [5-HT1B/1D] receptor agonists (triptans), seem to require headache onset in order to have an effect, while early treatment during mild pain before headache escalation improves short-term and long-term outcomes. Some patients find treating in the early window once headache has started but not escalated difficult, and migraine can arise from sleep or in the early hours of the morning, making prompt treatment after pain onset challenging. Triptans may be deemed unsuitable for use in patients with vascular disease and in those of older age and may not be effective in a proportion of patients. Headache is also increasingly recognised as being just one of the many facets of the migraine attack, and for some patients it is not the most disabling symptom. In many patients, painless symptoms can start prior to headache onset and can reliably warn of impending headache. There is, therefore, a need to identify therapeutic targets and agents that may be used as early as possible in the course of the attack, to prevent headache onset before it starts, and to reduce both headache and non-headache related attack burden. Early small studies using domperidone, naratriptan and dihydroergotamine have suggested that this approach could be useful; these studies were methodologically less rigorous than modern day treatment studies, of small sample size, and have not since been replicated. The emergence of novel targeted migraine treatments more recently, specifically calcitonin gene-related peptide (CGRP) receptor antagonists (gepants), has reignited interest in this strategy, with encouraging results. This review summarises historical and emerging data in this area, supporting use of the premonitory phase as an opportunity to intervene as early as possible in migraine to prevent attack-related morbidity.
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Affiliation(s)
- Nazia Karsan
- Headache Group, Wolfson SPaRC, Institute of Psychiatry, Psychology and Neuroscience, Wellcome Foundation Building, King's College London, Denmark Hill, London, SE5 9PJ, UK
- NIHR King's Clinical Research Facility and SLaM Biomedical Research Centre, King's College Hospital, London, UK
| | - Peter J Goadsby
- Headache Group, Wolfson SPaRC, Institute of Psychiatry, Psychology and Neuroscience, Wellcome Foundation Building, King's College London, Denmark Hill, London, SE5 9PJ, UK.
- NIHR King's Clinical Research Facility and SLaM Biomedical Research Centre, King's College Hospital, London, UK.
- Department of Neurology, University of California, Los Angeles, Los Angeles, CA, USA.
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Kirkland SW, Visser L, Meyer J, Junqueira DR, Campbell S, Villa-Roel C, Friedman BW, Essel NO, Rowe BH. The effectiveness of parenteral agents for pain reduction in patients with migraine presenting to emergency settings: A systematic review and network analysis. Headache 2024; 64:424-447. [PMID: 38644702 DOI: 10.1111/head.14704] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Revised: 01/16/2024] [Accepted: 01/29/2024] [Indexed: 04/23/2024]
Abstract
OBJECTIVES To assess the comparative effectiveness and safety of parenteral agents for pain reduction in patients with acute migraine. BACKGROUND Parenteral agents have been shown to be effective in treating acute migraine pain; however, the comparative effectiveness of different approaches is unclear. METHODS Nine electronic databases and gray literature sources were searched to identify randomized clinical trials assessing parenteral agents to treat acute migraine pain in emergency settings. Two independent reviewers completed study screening, data extraction, and Cochrane risk-of-bias assessment, with differences being resolved by adjudication. The protocol of the review was registered with the International Prospective Register of Systematic Reviews (PROSPERO; CRD42018100096). RESULTS A total of 97 unique studies were included, with most studies reporting a high or unclear risk of bias. Monotherapy, as well as combination therapy, successfully reduced pain scores prior to discharge. They also increased the proportion of patients reporting pain relief and being pain free. Across the pain outcomes assessed, combination therapy was one of the higher ranked approaches and provided robust improvements in pain outcomes, including lowering pain scores (mean difference -3.36, 95% confidence interval [CI] -4.64 to -2.08) and increasing the proportion of patients reporting pain relief (risk ratio [RR] 2.83, 95% CI 1.74-4.61). Neuroleptics and metoclopramide also ranked high in terms of the proportion of patients reporting pain relief (neuroleptics RR 2.76, 95% CI 2.12-3.60; metoclopramide RR 2.58, 95% CI 1.90-3.49) and being pain free before emergency department discharge (neuroleptics RR 4.8, 95% CI 3.61-6.49; metoclopramide RR 4.1, 95% CI 3.02-5.44). Most parenteral agents were associated with increased adverse events, particularly combination therapy and neuroleptics. CONCLUSIONS Various parenteral agents were found to provide effective pain relief. Considering the consistent improvements across various outcomes, combination therapy, as well as monotherapy of either metoclopramide or neuroleptics are recommended as first-line options for managing acute migraine pain. There are risks of adverse events, especially akathisia, following treatment with these agents. We recommend that a shared decision-making model be considered to effectively identify the best treatment option based on the patient's needs.
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Affiliation(s)
- Scott W Kirkland
- Department of Emergency Medicine, Faculty of Medicine & Dentistry, College of Health Sciences, University of Alberta, Edmonton, Alberta, Canada
| | - Lloyd Visser
- Department of Emergency Medicine, Faculty of Medicine & Dentistry, College of Health Sciences, University of Alberta, Edmonton, Alberta, Canada
| | - Jillian Meyer
- Department of Emergency Medicine, Faculty of Medicine & Dentistry, College of Health Sciences, University of Alberta, Edmonton, Alberta, Canada
| | | | - Sandra Campbell
- Health Sciences Library, University of Alberta, Edmonton, Alberta, Canada
| | - Cristina Villa-Roel
- Department of Emergency Medicine, Faculty of Medicine & Dentistry, College of Health Sciences, University of Alberta, Edmonton, Alberta, Canada
| | - Benjamin W Friedman
- Department of Emergency Medicine, Albert Einstein College of Medicine, New York, New York, USA
| | - Nana Owusu Essel
- Department of Emergency Medicine, Faculty of Medicine & Dentistry, College of Health Sciences, University of Alberta, Edmonton, Alberta, Canada
| | - Brian H Rowe
- Department of Emergency Medicine, Faculty of Medicine & Dentistry, College of Health Sciences, University of Alberta, Edmonton, Alberta, Canada
- School of Public Health, College of Health Sciences, University of Alberta, Edmonton, Alberta, Canada
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Cortel-LeBlanc MA, Orr SL, Dunn M, James D, Cortel-LeBlanc A. Managing and Preventing Migraine in the Emergency Department: A Review. Ann Emerg Med 2023; 82:732-751. [PMID: 37436346 DOI: 10.1016/j.annemergmed.2023.05.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Revised: 05/24/2023] [Accepted: 05/25/2023] [Indexed: 07/13/2023]
Abstract
Migraine is a leading cause of disability worldwide, and acute migraine attacks are a common reason for patients to seek care in the emergency department (ED). There have been recent advancements in the care of patients with migraine, specifically emerging evidence for nerve blocks and new pharmacological classes of medications like gepants and ditans. This article serves as a comprehensive review of migraine in the ED, including diagnosis and management of acute complications of migraine (eg, status migrainosus, migrainous infarct, persistent aura without infarction, and aura-triggered seizure) and use of evidence-based migraine-specific treatments in the ED. It highlights the role of migraine preventive medications and provides a framework for emergency physicians to prescribe them to eligible patients. Finally, it evaluates the evidence for nerve blocks in the treatment of migraine and introduces the possible role of gepants and ditans in the care of patients with migraine in the ED.
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Affiliation(s)
- Miguel A Cortel-LeBlanc
- Department of Emergency Medicine, Queensway Carleton Hospital, Ottawa, ON, Canada; Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada; Institut du Savoir Montfort, Ottawa, ON, Canada; 360 Concussion Care, Ottawa, ON, Canada.
| | - Serena L Orr
- Departments of Pediatrics, Community Health Sciences, and Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada; Alberta Children's Hospital Research Institute, University of Calgary, Calgary, AB, Canada
| | - Maeghan Dunn
- Department of Emergency Medicine, Queensway Carleton Hospital, Ottawa, ON, Canada
| | - Daniel James
- Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada; Department of Emergency Medicine, The Ottawa Hospital, Ottawa, ON, Canada; Department of Anesthesiology and Pain Medicine, The Ottawa Hospital, Ottawa, ON, Canada
| | - Achelle Cortel-LeBlanc
- Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada; Institut du Savoir Montfort, Ottawa, ON, Canada; 360 Concussion Care, Ottawa, ON, Canada; Division of Neurology, Department of Medicine, Queensway Carleton Hospital, Ottawa, ON, Canada
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Li C, Li Y, Zhang W, Ma Z, Xiao S, Xie W, Miao S, Li B, Lu G, Liu Y, Bai W, Yu S. Dopaminergic Projections from the Hypothalamic A11 Nucleus to the Spinal Trigeminal Nucleus Are Involved in Bidirectional Migraine Modulation. Int J Mol Sci 2023; 24:16876. [PMID: 38069205 PMCID: PMC10706593 DOI: 10.3390/ijms242316876] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Revised: 11/24/2023] [Accepted: 11/25/2023] [Indexed: 12/18/2023] Open
Abstract
Clinical imaging studies have revealed that the hypothalamus is activated in migraine patients prior to the onset of and during headache and have also shown that the hypothalamus has increased functional connectivity with the spinal trigeminal nucleus. The dopaminergic system of the hypothalamus plays an important role, and the dopamine-rich A11 nucleus may play an important role in migraine pathogenesis. We used intraperitoneal injections of glyceryl trinitrate to establish a model of acute migraine attack and chronicity in mice, which was verified by photophobia experiments and von Frey experiments. We explored the A11 nucleus and its downstream pathway using immunohistochemical staining and neuronal tracing techniques. During acute migraine attack and chronification, c-fos expression in GABAergic neurons in the A11 nucleus was significantly increased, and inhibition of DA neurons was achieved by binding to GABA A-type receptors on the surface of dopaminergic neurons in the A11 nucleus. However, the expression of tyrosine hydroxylase and glutamic acid decarboxylase proteins in the A11 nucleus of the hypothalamus did not change significantly. Specific destruction of dopaminergic neurons in the A11 nucleus of mice resulted in severe nociceptive sensitization and photophobic behavior. The expression levels of the D1 dopamine receptor and D2 dopamine receptor in the caudal part of the spinal trigeminal nucleus candalis of the chronic migraine model were increased. Skin nociceptive sensitization of mice was slowed by activation of the D2 dopamine receptor in SP5C, and activation of the D1 dopamine receptor reversed this behavioral change. GABAergic neurons in the A11 nucleus were activated and exerted postsynaptic inhibitory effects, which led to a decrease in the amount of DA secreted by the A11 nucleus in the spinal trigeminal nucleus candalis. The reduced DA bound preferentially to the D2 dopamine receptor, thus exerting a defensive effect against headache.
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Affiliation(s)
- Chenhao Li
- Department of Neurology, The First Medical Center of Chinese PLA General Hospital, Beijing 100853, China; (C.L.); (Y.L.); (W.Z.); (Z.M.); (S.X.); (W.X.); (S.M.); (B.L.); (G.L.); (Y.L.); (W.B.)
- Medical School of Chinese PLA, Beijing 100853, China
| | - Yang Li
- Department of Neurology, The First Medical Center of Chinese PLA General Hospital, Beijing 100853, China; (C.L.); (Y.L.); (W.Z.); (Z.M.); (S.X.); (W.X.); (S.M.); (B.L.); (G.L.); (Y.L.); (W.B.)
- Medical School of Chinese PLA, Beijing 100853, China
| | - Wenwen Zhang
- Department of Neurology, The First Medical Center of Chinese PLA General Hospital, Beijing 100853, China; (C.L.); (Y.L.); (W.Z.); (Z.M.); (S.X.); (W.X.); (S.M.); (B.L.); (G.L.); (Y.L.); (W.B.)
- School of Medicine, Nankai University, Tianjin 300071, China
| | - Zhenjie Ma
- Department of Neurology, The First Medical Center of Chinese PLA General Hospital, Beijing 100853, China; (C.L.); (Y.L.); (W.Z.); (Z.M.); (S.X.); (W.X.); (S.M.); (B.L.); (G.L.); (Y.L.); (W.B.)
- Medical School of Chinese PLA, Beijing 100853, China
| | - Shaobo Xiao
- Department of Neurology, The First Medical Center of Chinese PLA General Hospital, Beijing 100853, China; (C.L.); (Y.L.); (W.Z.); (Z.M.); (S.X.); (W.X.); (S.M.); (B.L.); (G.L.); (Y.L.); (W.B.)
- Medical School of Chinese PLA, Beijing 100853, China
| | - Wei Xie
- Department of Neurology, The First Medical Center of Chinese PLA General Hospital, Beijing 100853, China; (C.L.); (Y.L.); (W.Z.); (Z.M.); (S.X.); (W.X.); (S.M.); (B.L.); (G.L.); (Y.L.); (W.B.)
| | - Shuai Miao
- Department of Neurology, The First Medical Center of Chinese PLA General Hospital, Beijing 100853, China; (C.L.); (Y.L.); (W.Z.); (Z.M.); (S.X.); (W.X.); (S.M.); (B.L.); (G.L.); (Y.L.); (W.B.)
| | - Bozhi Li
- Department of Neurology, The First Medical Center of Chinese PLA General Hospital, Beijing 100853, China; (C.L.); (Y.L.); (W.Z.); (Z.M.); (S.X.); (W.X.); (S.M.); (B.L.); (G.L.); (Y.L.); (W.B.)
| | - Guangshuang Lu
- Department of Neurology, The First Medical Center of Chinese PLA General Hospital, Beijing 100853, China; (C.L.); (Y.L.); (W.Z.); (Z.M.); (S.X.); (W.X.); (S.M.); (B.L.); (G.L.); (Y.L.); (W.B.)
- Medical School of Chinese PLA, Beijing 100853, China
| | - Yingyuan Liu
- Department of Neurology, The First Medical Center of Chinese PLA General Hospital, Beijing 100853, China; (C.L.); (Y.L.); (W.Z.); (Z.M.); (S.X.); (W.X.); (S.M.); (B.L.); (G.L.); (Y.L.); (W.B.)
- Medical School of Chinese PLA, Beijing 100853, China
| | - Wenhao Bai
- Department of Neurology, The First Medical Center of Chinese PLA General Hospital, Beijing 100853, China; (C.L.); (Y.L.); (W.Z.); (Z.M.); (S.X.); (W.X.); (S.M.); (B.L.); (G.L.); (Y.L.); (W.B.)
| | - Shengyuan Yu
- Department of Neurology, The First Medical Center of Chinese PLA General Hospital, Beijing 100853, China; (C.L.); (Y.L.); (W.Z.); (Z.M.); (S.X.); (W.X.); (S.M.); (B.L.); (G.L.); (Y.L.); (W.B.)
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Zarei M, Hajipoor Kashgsaray N, Asheghi M, Shahabifard H, Soleimanpour H. Non-opioid Intravenous Drugs for Pain Management in Patients Presenting with Acute Migraine Pain in the Emergency Department: A Comprehensive Literature Review. Anesth Pain Med 2022; 12:e132904. [PMID: 36937180 PMCID: PMC10016134 DOI: 10.5812/aapm-132904] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2022] [Revised: 11/12/2022] [Accepted: 11/13/2022] [Indexed: 11/23/2022] Open
Abstract
Context Migraine is one of the most common causes of disability worldwide and the sixth cause of loss of life years due to disability. Migraine is reported mainly in young and middle-aged people, so it can cause a person to face many problems in doing daily tasks. The emergency department annually accepts 1.2 million patients with migraine. Therefore, timely diagnosis of the disease, knowledge of valuable drugs in an emergency, knowing how to use them, and finally, early treatment can play an essential and decisive role in improving patients' symptoms and reducing the disability caused by the disease. An essential and valuable drug category in the emergency department to manage pain is non-opioid intravenous (IV) drugs. Therefore, this study aimed to evaluate non-opioid IV drugs to manage pain in patients with acute migraines in the emergency department. Method This study conducted a comprehensive literature review to access the latest scientific studies and documents using keywords (acute migraine, non-opioid IV drugs, pain management) in reliable databases such as PubMed, Scopus, Web of Science, Cochrane, and Google Scholar. We reviewed 87 articles, 53 of which were evaluated and compared. Results A review study considers intravenous acetaminophen as a suitable option for the first-line treatment of acute migraine in the emergency department if the patient does not tolerate aspirin and non-steroidal anti-inflammatory drugs (NSAIDs). Various studies have obtained positive effects of NSAIDs and dihydroergotamine (DHE) in treating acute migraine. Prescribing anti-dopaminergic drugs can effectively reduce associated symptoms such as nausea and vomiting. Dexamethasone and magnesium sulfate are effective in preventing migraine and severe attacks. Intravenous sodium valproate is effective in moderate to severe migraine attacks or treatment-resistant migraines. In the emergency department, prescribing intravenous haloperidol, lidocaine, and propofol can help manage migraine and improve other associated symptoms, such as nausea or vomiting. Conclusions Non-opioid IV drugs are essential to manage pain and improve other migraine symptoms in the emergency setting. Knowing the above drugs and their optimal use has a decisive role in managing patients with acute migraine in the emergency department.
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Affiliation(s)
- Mahdi Zarei
- Student Research Committee, Tabriz University of Medical Sciences, Tabriz, Iran
| | | | - Milad Asheghi
- Student Research Committee, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Hesam Shahabifard
- Student Research Committee, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Hassan Soleimanpour
- Road Traffic Injury Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
- Corresponding Author: Road Traffic Injury Research Center, Tabriz University of Medical Sciences, Tabriz, Iran. ,
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Abstract
Headache disorders can produce recurrent, incapacitating pain. Migraine and cluster headache are notable for their ability to produce significant disability. The anatomy and physiology of headache disorders is fundamental to evolving treatment approaches and research priorities. Key concepts in headache mechanisms include activation and sensitization of trigeminovascular, brainstem, thalamic, and hypothalamic neurons; modulation of cortical brain regions; and activation of descending pain circuits. This review will examine the relevant anatomy of the trigeminal, brainstem, subcortical, and cortical brain regions and concepts related to the pathophysiology of migraine and cluster headache disorders.
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Affiliation(s)
- Andrea M Harriott
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Yulia Orlova
- Department of Neurology, University of Florida, Gainesville, Florida
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Ungrungseesopon N, Wongtanasarasin W. Pain reduction and adverse effects of intravenous metoclopramide for acute migraine attack: A systematic review and meta-analysis of randomized-controlled trials. World J Methodol 2022; 12:319-330. [PMID: 36159095 PMCID: PMC9350726 DOI: 10.5662/wjm.v12.i4.319] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Revised: 04/26/2022] [Accepted: 07/11/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Metoclopramide may be used to treat people suffering from acute migraine. However, no comprehensive investigation on this issue has been recorded. This review will provide more solid evidence for the use of metoclopramide in treating acute migraine.
AIM To compare the efficacy of intravenous metoclopramide with other therapies in migraine attack treatment in an emergency department (ED).
METHODS We included randomized controlled trials of participants older than 18 years with acute migraine headaches, which included at least one arm that received intravenous (IV) metoclopramide at the ED. A literature search of PubMed, Web of Science, Cochrane Collaboration, and Reference Citation Analysis on December 31, 2021 retrieved other drugs or placebo-controlled studies without language limitation. The risk of bias was assessed using the Cochrane risk of bias tool. The primary endpoint was pain reduction at 60 min or closest to 1 h after treatment, as measured by the pain scale. Secondary endpoints included adverse effects or reactions resulting from metoclopramide or comparisons.
RESULTS Fourteen trials with a total of 1661 individuals were eligible for review. The risk of bias ranged from low to intermediate. IV metoclopramide administration was not associated with higher pain reduction at 1 h (Standard mean difference [SMD] = -0.03, 95% confidence interval [CI]: -0.33-0.28, P = 0.87). However, metoclopramide was associated with better pain reduction than placebo (SMD = 1.04, 95%CI: 0.50-1.58, P = 0.0002). In addition, side effects were not significantly different between IV metoclopramide and other drugs or placebo (odds ratio [OR] = 0.76, 95%CI: 0.48-1.19, P = 0.09 and OR = 0.92, 95%CI: 0.31-2.74, P = 0.54, respectively).
CONCLUSION Metoclopramide is more effective than placebo in treating migraine in the ED. Despite the observed tendency of decreased side effects, its effectiveness compared to other regimens is poorly understood. More research on this area is needed to treat migraine in acute care settings effectively.
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Affiliation(s)
- Nat Ungrungseesopon
- Department of Emergency Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai 50200, Thailand
| | - Wachira Wongtanasarasin
- Department of Emergency Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai 50200, Thailand
- Department of Emergency Medicine, UC Davis School of Medicine, Sacramento, CA 95817, USA
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Rech MA, Griggs C, Lovett S, Motov S. Acute pain management in the Emergency Department: Use of multimodal and non-opioid analgesic treatment strategies. Am J Emerg Med 2022; 58:57-65. [DOI: 10.1016/j.ajem.2022.05.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Revised: 05/05/2022] [Accepted: 05/14/2022] [Indexed: 12/01/2022] Open
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Azimova Y, Amelin A, Alferova V, Artemenko A, Akhmadeeva L, Golovacheva V, Danilov A, Ekusheva E, Isagulian E, Koreshkina M, Kurushina O, Latysheva N, Lebedeva E, Naprienko M, Osipova V, Pavlov N, Parfenov V, Rachin A, Sergeev A, Skorobogatykh K, Tabeeva G, Filatova E. Clinical guidelines "Migraine". Zh Nevrol Psikhiatr Im S S Korsakova 2022. [DOI: 10.17116/jnevro20221220134] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Kazi F, Manyapu M, Fakherddine M, Mekuria K, Friedman BW. Second-line interventions for migraine in the emergency department: A narrative review. Headache 2021; 61:1467-1474. [PMID: 34806767 DOI: 10.1111/head.14239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Revised: 10/15/2021] [Accepted: 10/17/2021] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Millions of patients present to US emergency departments (ED) annually for the treatment of migraine. First-line treatments, including metoclopramide, prochlorperazine, and sumatriptan, fail to provide sufficient relief in up to one-third of treated patients. In this narrative review, we discuss the evidence supporting the use of injectable (intravenous, intramuscular, or subcutaneous) medications for patients in the ED who fail to improve sufficiently after treatment with first-line medication. METHODS We used the American Headache Society's guideline, "Management of Adults with Acute Migraine in the Emergency Department: The American Headache Society Evidence Assessment of Parenteral Pharmacotherapies," published in 2016, to identify first-line medications for migraine. We then conducted a PubMed search to determine whether any evidence supported the use of these medications as second-line therapy and whether any evidence existed to support the use of injectable therapies not discussed in the guideline as second-line therapy. RESULTS We identified only scant high-quality randomized data of second-line therapy. Therefore, we based our recommendations on medications that have reliably demonstrated efficacy as first-line treatment of migraine. These medications include injectable non-steroidal anti-inflammatory drugs (NSAIDs) and acetaminophen. Dihydroergotamine and valproic acid have some data supporting efficacy. More recently, greater occipital nerve blocks (GONBs) have been shown to be efficacious. With the exception of meperidine, opioids have been shown to be not efficacious. Most data published to date demonstrate no role for propofol and ketamine. CONCLUSIONS There are no evidence-based second-line treatments of migraine in the ED setting. For patients with migraine, who fail to improve after treatment with a first-line medication, it is reasonable to use an intravenous NSAID or intravenous acetaminophen. Alternatively, clinicians adept at performing a GONB may offer this treatment.
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Affiliation(s)
- Farnam Kazi
- Department of Emergency Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, New York, USA
| | - Mallika Manyapu
- Department of Emergency Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, New York, USA
| | - Maha Fakherddine
- Department of Emergency Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, New York, USA
| | - Kumelachew Mekuria
- Department of Emergency Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, New York, USA
| | - Benjamin W Friedman
- Department of Emergency Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, New York, USA
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VanderPluym JH, Halker Singh RB, Urtecho M, Morrow AS, Nayfeh T, Torres Roldan VD, Farah MH, Hasan B, Saadi S, Shah S, Abd-Rabu R, Daraz L, Prokop LJ, Murad MH, Wang Z. Acute Treatments for Episodic Migraine in Adults: A Systematic Review and Meta-analysis. JAMA 2021; 325:2357-2369. [PMID: 34128998 PMCID: PMC8207243 DOI: 10.1001/jama.2021.7939] [Citation(s) in RCA: 48] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
IMPORTANCE Migraine is common and can be associated with significant morbidity, and several treatment options exist for acute therapy. OBJECTIVE To evaluate the benefits and harms associated with acute treatments for episodic migraine in adults. DATA SOURCES Multiple databases from database inception to February 24, 2021. STUDY SELECTION Randomized clinical trials and systematic reviews that assessed effectiveness or harms of acute therapy for migraine attacks. DATA EXTRACTION AND SYNTHESIS Independent reviewers selected studies and extracted data. Meta-analysis was performed with the DerSimonian-Laird random-effects model with Hartung-Knapp-Sidik-Jonkman variance correction or by using a fixed-effect model based on the Mantel-Haenszel method if the number of studies was small. MAIN OUTCOMES AND MEASURES The main outcomes included pain freedom, pain relief, sustained pain freedom, sustained pain relief, and adverse events. The strength of evidence (SOE) was graded with the Agency for Healthcare Research and Quality Methods Guide for Effectiveness and Comparative Effectiveness Reviews. FINDINGS Evidence on triptans and nonsteroidal anti-inflammatory drugs was summarized from 15 systematic reviews. For other interventions, 115 randomized clinical trials with 28 803 patients were included. Compared with placebo, triptans and nonsteroidal anti-inflammatory drugs used individually were significantly associated with reduced pain at 2 hours and 1 day (moderate to high SOE) and increased risk of mild and transient adverse events. Compared with placebo, calcitonin gene-related peptide receptor antagonists (low to high SOE), lasmiditan (5-HT1F receptor agonist; high SOE), dihydroergotamine (moderate to high SOE), ergotamine plus caffeine (moderate SOE), acetaminophen (moderate SOE), antiemetics (low SOE), butorphanol (low SOE), and tramadol in combination with acetaminophen (low SOE) were significantly associated with pain reduction and increase in mild adverse events. The findings for opioids were based on low or insufficient SOE. Several nonpharmacologic treatments were significantly associated with improved pain, including remote electrical neuromodulation (moderate SOE), transcranial magnetic stimulation (low SOE), external trigeminal nerve stimulation (low SOE), and noninvasive vagus nerve stimulation (moderate SOE). No significant difference in adverse events was found between nonpharmacologic treatments and sham. CONCLUSIONS AND RELEVANCE There are several acute treatments for migraine, with varying strength of supporting evidence. Use of triptans, nonsteroidal anti-inflammatory drugs, acetaminophen, dihydroergotamine, calcitonin gene-related peptide antagonists, lasmiditan, and some nonpharmacologic treatments was associated with improved pain and function. The evidence for many other interventions, including opioids, was limited.
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Affiliation(s)
- Juliana H. VanderPluym
- Mayo Clinic Evidence-based Practice Center, Rochester, Minnesota
- Department of Neurology, Mayo Clinic, Scottsdale, Arizona
| | - Rashmi B. Halker Singh
- Mayo Clinic Evidence-based Practice Center, Rochester, Minnesota
- Department of Neurology, Mayo Clinic, Scottsdale, Arizona
| | - Meritxell Urtecho
- Mayo Clinic Evidence-based Practice Center, Rochester, Minnesota
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota
| | - Allison S. Morrow
- Mayo Clinic Evidence-based Practice Center, Rochester, Minnesota
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota
| | - Tarek Nayfeh
- Mayo Clinic Evidence-based Practice Center, Rochester, Minnesota
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota
| | - Victor D. Torres Roldan
- Mayo Clinic Evidence-based Practice Center, Rochester, Minnesota
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota
| | - Magdoleen H. Farah
- Mayo Clinic Evidence-based Practice Center, Rochester, Minnesota
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota
| | - Bashar Hasan
- Mayo Clinic Evidence-based Practice Center, Rochester, Minnesota
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota
| | - Samer Saadi
- Mayo Clinic Evidence-based Practice Center, Rochester, Minnesota
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota
| | - Sahrish Shah
- Mayo Clinic Evidence-based Practice Center, Rochester, Minnesota
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota
| | - Rami Abd-Rabu
- Mayo Clinic Evidence-based Practice Center, Rochester, Minnesota
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota
| | - Lubna Daraz
- Mayo Clinic Evidence-based Practice Center, Rochester, Minnesota
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota
| | - Larry J. Prokop
- Department of Library–Public Services, Mayo Clinic, Rochester, Minnesota
| | - Mohammad Hassan Murad
- Mayo Clinic Evidence-based Practice Center, Rochester, Minnesota
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota
| | - Zhen Wang
- Mayo Clinic Evidence-based Practice Center, Rochester, Minnesota
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota
- Division of Health Care Delivery Research, Mayo Clinic, Rochester, Minnesota
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12
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Wong A, Potter J, Brown NJ, Chu K, Hughes JA. Patient-Reported outcomes of pain care research in the adult emergency department: A scoping review. Australas Emerg Care 2020; 24:127-134. [PMID: 33187935 DOI: 10.1016/j.auec.2020.10.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Revised: 10/12/2020] [Accepted: 10/20/2020] [Indexed: 12/19/2022]
Abstract
Despite more than 30 years of research, pain in the emergency department (ED) setting is frequently undertreated. EDs prioritise process measures that often have tenuous links to patient-reported outcomes. However, process measures, such as time to the administration of first analgesic medication, are neither direct objective measures of analgesia nor appropriate surrogate markers of pain relief. Since pain is a subjective symptom that lacks an objective measure, pain research in any clinical environment, including EDs, should rely upon patient-reported outcomes. This scoping review examined patient-reported outcomes (PROs) and patient-reported outcome measures (PROMs) of pain care in the adult emergency department at the micro, meso and macro-level over the last ten years. We reviewed pain care research conducted on adults in EDs over the last ten years and identified 57 articles using 14 patient-reported outcomes of pain care falling into five broad areas, most without validation or adaption to the ED setting. Despite efforts made to incorporate PROs and PROMs into acute pain care research in the ED over the last ten years, there is still no gold-standard PROM in widespread use. We recommend the adaptation of existing tools with rigorous validation in ED populations.
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Affiliation(s)
- Alixandra Wong
- Faculty of Medicine, University of Queensland, St Lucia, Australia
| | - Joseph Potter
- Faculty of Medicine, University of Queensland, St Lucia, Australia; Logan Hospital, Meadowbrook, Australia
| | - Nathan J Brown
- Faculty of Medicine, University of Queensland, St Lucia, Australia; Emergency and Trauma Centre, Royal Brisbane and Women's Hospital, Herston, Australia
| | - Kevin Chu
- Faculty of Medicine, University of Queensland, St Lucia, Australia; Emergency and Trauma Centre, Royal Brisbane and Women's Hospital, Herston, Australia
| | - James A Hughes
- Emergency and Trauma Centre, Royal Brisbane and Women's Hospital, Herston, Australia; School of Nursing, Queensland University of Technology, Kelvin Grove, Australia.
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13
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Beach SR, Gross AF, Hartney KE, Taylor JB, Rundell JR. Intravenous haloperidol: A systematic review of side effects and recommendations for clinical use. Gen Hosp Psychiatry 2020; 67:42-50. [PMID: 32979582 DOI: 10.1016/j.genhosppsych.2020.08.008] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Revised: 08/17/2020] [Accepted: 08/18/2020] [Indexed: 12/19/2022]
Abstract
INTRODUCTION Though not approved by the United States Food and Drug Administration, intravenous haloperidol (IVH) is widely used off-label to manage agitation and psychosis in patients with delirium in the hospital setting. Over the years, concerns have emerged regarding side effects of IVH, particularly its potential to cause QT prolongation, torsades de pointes (TdP), extrapyramidal symptoms and catatonia. METHODS We conducted a systematic review of literature of published literature related to side effects of IVH in PubMed in accordance with PRISMA guidelines. RESULTS 77 of 196 identified manuscripts met inclusion criteria, including 34 clinical trials and 34 case reports or series. DISCUSSION Extrapyramidal symptoms, catatonia and neuroleptic malignant syndrome appears to be relatively rare with IVH. In most prospective studies, IVH did not cause greater QT prolongation than placebo, and rates of TdP with IVH appear to be low. There is not clear evidence to suggest that IVH carries greater risk for QT prolongation or TdP than other antipsychotics. CONCLUSIONS Based on the available literature, we provide modified evidence-based monitoring recommendations for clinicians prescribing IVH in hospital settings. Specifically, we recommend electrocardiogram monitoring only when using doses >5 mg of IVH and telemetry only for high-risk patients receiving cumulative doses of at least 100 mg or with accurately corrected QTc >500 ms.
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Affiliation(s)
- Scott R Beach
- Department of Psychiatry, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States of America.
| | - Anne F Gross
- Department of Psychiatry, Oregon Health & Science University, Portland, OR, United States of America
| | - Kimberly E Hartney
- Department of Psychiatry, University of South Florida, Tampa, FL, United States of America
| | - John B Taylor
- Department of Psychiatry, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States of America
| | - James R Rundell
- Department of Psychiatry, Uniformed Services University of the Health Sciences School of Medicine, Bethesda, MD, United States of America
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Schulte LH, Menz MM, Haaker J, May A. The migraineur’s brain networks: Continuous resting state fMRI over 30 days. Cephalalgia 2020; 40:1614-1621. [DOI: 10.1177/0333102420951465] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Objective The aim of the current study was to identify typical alterations in resting state connectivity within different stages of the migraine cycle and to thus explore task-free mechanisms of headache attack generation in migraineurs. Background Recent evidence in migraine pathophysiology suggests that hours and even days before headache certain changes in brain activity take place, ultimately leading to an attack. Here, we investigate changes before headache onset using resting state functional magnetic resonance imaging (fMRI). Methods Nine episodic migraineurs underwent daily resting state functional magnetic resonance imaging for a minimum period of 30 consecutive days, leading to a cumulative number of 282 total days scanned. Thus, data from 15 spontaneous headache attacks were acquired. This allows analysing not only the ictal and the interictal phase of migraine but also the preictal phase. ROI-to-ROI (region of interest) and ROI-to-voxel connectivity was calculated over the migraine cycle. Results Within the ROI-to-ROI analysis, the right nucleus accumbens showed enhanced functional connectivity to the left amygdala, hippocampus and gyrus parahippocampalis in the preictal phase compared to the interictal phase. ROI-to-voxel connectivity of the right accumbens with the dorsal rostral pons was enhanced during the preictal phase compared to interictally. Regarding custom defined ROIs, the dorsal pons was ictally functionally more strongly coupled to the hypothalamic area than interictally. Conclusions This unique data set suggests that particularly connectivity changes in dopaminergic centres and between the dorsal pons and the hypothalamus are important within migraine attack generation and sustainment.
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Affiliation(s)
- Laura H Schulte
- Department of Systems Neuroscience, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- Clinic for Psychiatry, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Mareike M Menz
- Department of Systems Neuroscience, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jan Haaker
- Department of Systems Neuroscience, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Arne May
- Department of Systems Neuroscience, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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15
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McCoy JJ, Aldy K, Arnall E, Petersen J. Treatment of Headache in the Emergency Department: Haloperidol in the Acute Setting (THE-HA Study): A Randomized Clinical Trial. J Emerg Med 2020; 59:12-20. [PMID: 32402480 DOI: 10.1016/j.jemermed.2020.04.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2019] [Revised: 03/09/2020] [Accepted: 04/08/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Headache is a common complaint of emergency department (ED) patients and current treatment varies with significant limitations. OBJECTIVE Our aim was to evaluate the efficacy and safety of 2.5 mg i.v. haloperidol in the treatment of severe benign headache in the ED. METHODS A randomized, double-blind, placebo-controlled trial was performed in the ED of a single high-volume teaching hospital. Convenience sampling identified 287 eligible patients 13 to 55 years old with benign headache. One hundred and eighteen patients were enrolled to receive either 2.5 mg of haloperidol i.v. or placebo. The primary outcome measure was pain reduction at 60 min. Patients were evaluated for adverse events and follow-up was conducted after discharge. QT measurement was performed at baseline and discharge. RESULTS Fifty-eight patients received haloperidol and 60 patients received placebo. Patients in the haloperidol group reported an average 4.77-unit reduction in visual analogue scale score at 60 min compared to a 1.87-unit reduction in the control group. Thirty-four patients (58.6%) in the haloperidol group had complete resolution of their headache. Treatment with rescue ketorolac was required in 78.3% of the control group and 31% of the haloperidol group. Adverse events were uncommon, benign, and easily treated. No patients in the haloperidol group were found to have QT lengthening. CONCLUSIONS This study suggests that 2.5 mg i.v. haloperidol is a rapid and effective treatment for acute, severe, benign headache in ED patients aged 18 to 55 years. Further study is warranted to confirm these results in adolescents. TRIAL REGISTRATION ClinicalTrials.gov Identifier NCT02747511.
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Affiliation(s)
- Jessica J McCoy
- Department of Emergency Medicine, Western Michigan University, Homer Stryker M.D. School of Medicine, Kalamazoo, Michigan
| | - Kim Aldy
- Department of Emergency Medicine, Western Michigan University, Homer Stryker M.D. School of Medicine, Kalamazoo, Michigan
| | - Elizabeth Arnall
- Department of Emergency Medicine, Western Michigan University, Homer Stryker M.D. School of Medicine, Kalamazoo, Michigan
| | - Joshua Petersen
- Emergency Department, Bronson Methodist Hospital, Kalamazoo, Michigan
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16
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QTc prolongation after haloperidol administration in critically ill patients post cardiovascular surgery: A cohort study and review of the literature. Palliat Support Care 2020; 18:447-459. [DOI: 10.1017/s1478951520000231] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
AbstractObjectiveFrom case reports, haloperidol administration has been associated with QTc prolongation, torsades de pointes, and sudden cardiac death. In a vulnerable population of critically ill patients after cardiac surgery, however, it is unclear whether haloperidol administration affects the QTc interval. Thus, the aim of this study is to explore the effect of haloperidol in low doses on this interval.MethodThis retrospective cohort study was performed on a cardio-surgical intensive care unit (ICU), screened 2,216 patients and eventually included 68 patients with delirium managed with oral and intravenous haloperidol. In this retrospective analysis, electrocardiograms were taken prior and within 24 h after haloperidol administration. The effect of haloperidol on QTc was determined with a Person correlation, and inter-group differences were measured with new long QT comparisons.ResultsIn total, 68 patients were included, the median age was 71 (64–79) years and predominantly male (77%). Haloperidol administration followed ICU admission by three days and the cumulative dose was 4 (2–9) mg. As a result, haloperidol administration did not affect the QTc (r = 0.144, p = 0.23). In total, 31% (21/68 patients) had a long QT before and 27.9% (19/68 patients) after haloperidol administration. Only 12% (8/68 patients) developed a newly onset long QT. These patients were not different in the route of administration, cumulative haloperidol doses, comorbidities, laboratory findings, or medications.Significance of resultsThese results indicated that low-dose intravenous haloperidol was safe and not clinically relevant for the development of a newly onset long QT syndrome or adverse outcomes and support recent findings inside and outside the ICU setting.
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Godwin SA, Cherkas DS, Panagos PD, Shih RD, Byyny R, Wolf SJ. Clinical Policy: Critical Issues in the Evaluation and Management of Adult Patients Presenting to the Emergency Department With Acute Headache. Ann Emerg Med 2020; 74:e41-e74. [PMID: 31543134 DOI: 10.1016/j.annemergmed.2019.07.009] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
This clinical policy from the American College of Emergency Physicians addressed key issues in the evaluation and management of adult patients presenting to the emergency department with acute headache. A writing subcommittee conducted a systematic review of the literature to derive evidence-based recommendations to answer the following clinical questions: (1) In the adult emergency department patient presenting with acute headache, are there risk-stratification strategies that reliably identify the need for emergent neuroimaging? (2) In the adult emergency department patient treated for acute primary headache, are nonopioids preferred to opioid medications? (3) In the adult emergency department patient presenting with acute headache, does a normal noncontrast head computed tomography scan performed within 6 hours of headache onset preclude the need for further diagnostic workup for subarachnoid hemorrhage? (4) In the adult emergency department patient who is still considered to be at risk for subarachnoid hemorrhage after a negative noncontrast head computed tomography, is computed tomography angiography of the head as effective as lumbar puncture to safely rule out subarachnoid hemorrhage? Evidence was graded and recommendations were made based on the strength of the available data.
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18
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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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Dolgorukova A, Osipchuk AV, Murzina AA, Sokolov AY. The Influence of Metoclopramide on Trigeminovascular Nociception: Possible Anti-migraine Mechanism of Action. Neuroscience 2019; 425:123-133. [PMID: 31785356 DOI: 10.1016/j.neuroscience.2019.11.026] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2019] [Revised: 11/05/2019] [Accepted: 11/15/2019] [Indexed: 12/20/2022]
Abstract
Metoclopramide is widely used as an abortive migraine therapy due to the advantage of having not only antiemetic, but also analgesic properties. Despite the proven clinical efficacy of metoclopramide in acute migraine, the mechanism of its anti-cephalalgic action has not been entirely elucidated. Taking into account the key role of the trigeminovascular system activation in migraine pathophysiology, we aimed to investigate metoclopramide effects on the excitability of central trigeminovascular neurons and neurogenic dural vasodilation using valid electrophysiological and neurovascular models of trigeminovascular nociception. Extracellular recordings of the activity of second-order dura-sensitive neurons were made in the trigeminocervical complex (TCC) of 16 anaesthetised rats. Cumulative metoclopramide infusion (three steps in 30 min intervals, 5 mg/kg i.v. per step, n = 8) significantly and dose-dependently suppressed both ongoing firing of the TCC neurons and their responses to dural electrical stimulation, maximally to 30%[0-49%] (median[Q1-Q3]) and 4%[0-30%] of the initial level, respectively (both p = 0.001, compared to saline (n = 8)). By contrast, the neurogenic dural vasodilation studied in a separate group of 12 rats was not significantly affected by cumulative infusion of metoclopramide (5 mg/kg i.v. per step, n = 6) compared to both baseline values and the vehicle group (n = 6) (all p > 0.05). These results provide evidence that metoclopramide is unable to affect the peripheral response to trigeminovascular activation, but it does suppress the central response, which is highly predictive of anti-migraine action. Thus, here we show the neurophysiological mechanism underlying the therapeutic efficacy of metoclopramide in migraine.
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Affiliation(s)
- Antonina Dolgorukova
- Department of Neuropharmacology, Valdman Institute of Pharmacology, Pavlov First Saint Petersburg State Medical University, L'va Tolstogo str. 6-8, 197022 Saint Petersburg, Russia.
| | - Anastasiia V Osipchuk
- Department of Neuropharmacology, Valdman Institute of Pharmacology, Pavlov First Saint Petersburg State Medical University, L'va Tolstogo str. 6-8, 197022 Saint Petersburg, Russia
| | - Anna A Murzina
- Department of Neuropharmacology, Valdman Institute of Pharmacology, Pavlov First Saint Petersburg State Medical University, L'va Tolstogo str. 6-8, 197022 Saint Petersburg, Russia
| | - Alexey Y Sokolov
- Department of Neuropharmacology, Valdman Institute of Pharmacology, Pavlov First Saint Petersburg State Medical University, L'va Tolstogo str. 6-8, 197022 Saint Petersburg, Russia; Laboratory of Cortico-Visceral Physiology, Pavlov Institute of Physiology of the Russian Academy of Sciences, Nab. Makarova 6, 199034 Saint Petersburg, Russia
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20
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Abstract
BACKGROUND In this study, we will assess the efficacy and safety of metoclopramide for the treatment of acute migraine (AM). METHODS We will comprehensively search Cochrane Library, PUMBED, EMBASE, Google Scholar, Web of Science, Allied and Complementary Medicine Database, Chinese Biomedical Literature Database, and China National Knowledge Infrastructure from the inception to July 1, 2019 to identify any eligible studies. Only randomized controlled trials will be considered for inclusion. The study selection, data collection, and management will be completed by two authors independently. The risk of bias will be assessed using Cochrane risk of bias tool. RevMan 5.3 software will be used for statistical analysis. RESULTS The primary outcome includes pain intensity, as measured by visual analogue scale or others. The secondary outcomes are success rate, requirement of rescue medicine, quality of life, relapse, and adverse events. CONCLUSIONS This study will summarize the latest evidence for the clinical efficacy and safety of metoclopramide for the treatment of AM. PROSPERO REGISTRATION NUMBER PROSPERO CRD42019142795.
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Affiliation(s)
- Chao Jiang
- The Third Department of Neurology, The Second Affiliated Hospital of Xi’an Medical University, Xi’an
- Department of Emergency, Longhua Hospital Shanghai University of Traditional Chinese Medicine, Shanghai
| | - Ting Wang
- School of Economics and Management, Xi Dian University, Xi’an
| | - Zheng-guo Qiu
- Department of Anesthesiology, The Second Affiliated Hospital of Xi’an Medical University
| | - Bo Chen
- Department of Anesthesiology, The Hospital of Xidian Group, Xi’an, Shaanxi, China
| | - Bang-jiang Fang
- Department of Emergency, Longhua Hospital Shanghai University of Traditional Chinese Medicine, Shanghai
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Abstract
BACKGROUND The clinical picture, but also neuroimaging findings, suggested the brainstem and midbrain structures as possible driving or generating structures in migraine. FINDINGS This has been intensely discussed in the last decades and the advent of modern imaging studies refined the involvement of rostral parts of the pons in acute migraine attacks, but more importantly suggested a predominant role of the hypothalamus and alterations in hypothalamic functional connectivity shortly before the beginning of migraine headaches. This was shown in the NO-triggered and also in the preictal stage of native human migraine attacks. Another headache type that is clinically even more suggestive of hypothalamic involvement is cluster headache, and indeed a structure in close proximity to the hypothalamus has been identified to play a crucial role in attack generation. CONCLUSION It is very likely that spontaneous oscillations of complex networks involving the hypothalamus, brainstem, and dopaminergic networks lead to changes in susceptibility thresholds that ultimately start but also terminate headache attacks. We will review clinical and neuroscience evidence that puts the hypothalamus in the center of scientific attention when attack generation is discussed.
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Affiliation(s)
- Arne May
- Department of Systems Neuroscience, University Medical Center Eppendorf, Hamburg, Germany
| | - Rami Burstein
- Department of Anesthesia and Critical Care, Beth Israel Deaconess Medical center, Department of Anesthesia, Harvard medical School, Boston, MA, USA
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Abstract
Migraine headaches account for approximately 1.2 million emergency department (ED) visits annually. Despite the prevalence of this condition, there is little consensus on the best pharmacotherapeutic interventions to use in the ED setting. Guidelines published by the American Headache Society and the Canadian Headache Society offer some direction to ED providers but are not widely utilized. This article reviews the best evidence behind some of the medications frequently used to treat acute migraines in the ED setting, including dopamine receptor antagonists, serotonin receptor agonists, anti-inflammatory medications, opioids, magnesium, valproate, and propofol. The evaluation of patients presenting to the ED with an acute headache, the diagnostic criteria for migraines, and implications for advanced practice are also discussed.
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Affiliation(s)
- Robert Goodnough
- Department of Emergency Medicine, University of California San Francisco, San Francisco, California; California Poison Control System, San Francisco Division, San Francisco, California
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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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Miller AC, Khan AM, Castro Bigalli AA, Sewell KA, King AR, Ghadermarzi S, Mao Y, Zehtabchi S. Neuroleptanalgesia for acute abdominal pain: a systematic review. J Pain Res 2019; 12:787-801. [PMID: 30881092 PMCID: PMC6396833 DOI: 10.2147/jpr.s187798] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Acute abdominal pain (AAP) comprises up to 10% of all emergency department (ED) visits. Current pain management practice is moving toward multi-modal analgesia regimens that decrease opioid use. OBJECTIVE This project sought to determine whether, in patients with AAP (population), does administration of butyrophenone antipsychotics (intervention) compared to placebo, usual care, or opiates alone (comparisons) improve analgesia or decrease opiate consumption (outcomes)? METHODS A structured search was performed in Cochrane CENTRAL, CINAHL, Database of Abstracts of Reviews of Effects, Directory of Open Access Journals, Embase, IEEE-Xplorer, Latin American and Caribbean Health Sciences Literature, Magiran, PubMed, Scientific Information Database, Scopus, TÜBİTAK ULAKBİM, and Web of Science. Clinical trial registries (ClinicalTrials.gov, World Health Organization International Clinical Trials Registry Platform, and Australian New Zealand Clinical Trials Registry), relevant bibliographies, and conference proceedings were also searched. Searches were not limited by date, language, or publication status. Studies eligible for inclusion were prospective randomized clinical trials enrolling patients (age ≥18 years) with AAP treated in acute care environments (ED, intensive care unit, postoperative). The butyrophenone must have been administered either intravenously or intra-muscularly. Comparison groups included placebo, opiate only, corticosteroids, non-steroidal anti-inflammatory drugs, or acetaminophen. RESULTS We identified 7,217 references. Six studies met inclusion criteria. One study assessed ED patients with AAP associated with gastroparesis, whereas five studies assessed patients with postoperative AAP: abdominal hysterectomy (n=4), sleeve gastrectomy (n=1). Three of four studies found improvements in pain intensity with butyrophenone use. Three of five studies reported no change in postoperative opiate consumption, while two reported a decrease. One ED study reported no change in patient satisfaction, while one postoperative study reported improved satisfaction scores. Both extrapyramidal side effects (n=3) and sedation (n=3) were reported as unchanged. CONCLUSION Based on available evidence, we cannot draw a conclusion on the efficacy or benefit of neuroleptanalgesia in the management of patients with AAP. However, preliminary data suggest that it may improve analgesia and decrease opiate consumption.
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Affiliation(s)
- Andrew C Miller
- Department of Emergency Medicine, Vidant Medical Center, Brody School of Medicine, East Carolina University, Greenville, NC, USA,
- The MORZAK Collaborative, Orlando, FL, USA,
| | | | | | - Kerry A Sewell
- William E. Laupus Health Sciences Library, East Carolina University, Greenville, NC, USA
| | - Alexandra R King
- Division of Emergency Medicine and Toxicology, Department of Pharmacy, Vidant Medical Center, Greenville, NC, USA
| | - Shadi Ghadermarzi
- Department of Internal Medicine, Vidant Medical Center, East Carolina University Brody School of Medicine, Greenville, NC, USA
| | - Yuxuan Mao
- Department of Internal Medicine, Vidant Medical Center, East Carolina University Brody School of Medicine, Greenville, NC, USA
| | - Shahriar Zehtabchi
- Department of Emergency Medicine, State University of New York Downstate Medical Center, Brooklyn, NY, USA
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Cisewski DH, Motov SM. Essential pharmacologic options for acute pain management in the emergency setting. Turk J Emerg Med 2019; 19:1-11. [PMID: 30793058 PMCID: PMC6370909 DOI: 10.1016/j.tjem.2018.11.003] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2018] [Accepted: 11/30/2018] [Indexed: 12/19/2022] Open
Abstract
Pain is the root cause for the overwhelming majority of emergency department (ED) visits worldwide. However, pain is often undertreated due to inappropriate analgesic dosing and ineffective utilization of available analgesics. It is essential for emergency providers to understand the analgesic armamentarium at their disposal and how it can be used safely and effectively to treat pain of every proportion within the emergency setting. A 'balanced analgesia' regimen may be used to treat pain while reducing the overall pharmacologic side effect profile of the combined analgesics. Channels-Enzymes-Receptors Targeted Analgesia (CERTA) is a multimodal analgesic strategy incorporating balanced analgesia by shifting from a system-based to a mechanistic-based approach to pain management that targets the physiologic pathways involved in pain signaling transmission. Targeting individual pain pathways allows for a variety of reduced-dose pharmacologic options - both opioid and non-opioid - to be used in a stepwise progression of analgesic strength as pain advances up the severity scale. By developing a familiarity with the various analgesic options at their disposal, emergency providers may formulate safe, effective, balanced analgesic combinations unique to each emergency pain presentation.
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Affiliation(s)
- David H. Cisewski
- Icahn School of Medicine at Mount Sinai Hospital, Department of Emergency Medicine, New York, NY, USA
| | - Sergey M. Motov
- Maimonides Medical Center, Department of Emergency Medicine, Brooklyn, NY, USA
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27
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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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Benign Headache Management in the Emergency Department. J Emerg Med 2018; 54:458-468. [DOI: 10.1016/j.jemermed.2017.12.023] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2017] [Accepted: 12/01/2017] [Indexed: 01/08/2023]
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Tfelt-Hansen P, Lindqvist JK, Do TP. Evaluating the reporting of adverse events in controlled clinical trials conducted in 2010–2015 on migraine drug treatments. Cephalalgia 2018; 38:1885-1895. [DOI: 10.1177/0333102418759785] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Background In 2008, the International Headache Society published guidelines on the “evaluation and registration of adverse events in clinical drug trials on migraine”. They listed seven recommendations for reporting adverse events in randomized controlled trials on migraine. The present study aimed to evaluate adherence to these recommendations, and based on the results, to recommend improvements. Methods We searched the PubMed/MEDLINE database to identify controlled trials on migraine drugs published from 2010 to 2015. For each trial, we noted whether five of the recommended parameters were presented. In addition, we noted whether adverse events were reported in abstracts. Results We identified 73 trials; 51 studied acutely administered drugs and 22 studied prophylactic drugs for migraine. The number of patients with any adverse events were reported in 74% of acute-administration and 86% of prophylactic drug trials. Only 30 (41%) of the 73 studies reported adverse events with data in the abstracts, and 27 (37%) abstracts did not mention adverse events. Conclusion Adverse events, both frequency and symptoms, should be reported to allow a fair judgement of benefit/tolerability ratio when randomized controlled trials in migraine treatment are published. Clinically significant adverse events should be included in the abstract of every randomized controlled trial in migraine treatment.
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Affiliation(s)
- Peer Tfelt-Hansen
- Danish Headache Center and Department of Neurology, Rigshospitalet-Glostrup, Faculty of Health Sciences, University of Copenhagen, Glostrup, Denmark
| | | | - Thien Phu Do
- Danish Headache Center and Department of Neurology, Rigshospitalet-Glostrup, Faculty of Health Sciences, University of Copenhagen, Glostrup, Denmark
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30
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Schmidt A, Fischer P, Wally B, Scharfetter J. Influence of intravenous administration of the antipsychotic drug benperidol on the QT interval. NEUROPSYCHIATRIE : KLINIK, DIAGNOSTIK, THERAPIE UND REHABILITATION : ORGAN DER GESELLSCHAFT OSTERREICHISCHER NERVENARZTE UND PSYCHIATER 2017; 31:172-175. [PMID: 28791627 DOI: 10.1007/s40211-017-0230-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/28/2017] [Accepted: 06/01/2017] [Indexed: 06/07/2023]
Abstract
A group effect is generally assumed regarding the prolongation of the QT interval through butyrophenone antipsychotics like haloperidol. Consequently intravenous administration of benperidol is seen critically notwithstanding sparse evidence; thus benperidol and haloperidol were compared regarding their cardiac risk of prolonging the QT interval when administered intravenously for acute sedation of psychotic patients. The QT interval was measured by a 12-lead ECG. For the correction of QT values Bazett's formula was used. The resulting QTc intervals of the benperidol and the haloperidol group were compared using Mann-Whitney U-test. Our data provide statistical evidence for benperidol being less prone to cause QTc prolongation than haloperidol (p = 0.049). The results of our study indicate a more favourable risk profile of benperidol compared to haloperidol regarding QTc prolongation when administered intravenously.
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Affiliation(s)
- Alexander Schmidt
- Department for Pharmacology and Toxicology, University Vienna, Vienna, Austria.
| | - Peter Fischer
- Teaching Hospital, Department for Psychiatry, Donauspital Vienna, Vienna, Austria
| | - Beate Wally
- Teaching Hospital, Department for Psychiatry, Donauspital Vienna, Vienna, Austria
| | - Joachim Scharfetter
- Teaching Hospital, Department for Psychiatry, Donauspital Vienna, Vienna, Austria
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Roldan CJ, Chambers KA, Paniagua L, Patel S, Cardenas-Turanzas M, Chathampally Y. Randomized Controlled Double-blind Trial Comparing Haloperidol Combined With Conventional Therapy to Conventional Therapy Alone in Patients With Symptomatic Gastroparesis. Acad Emerg Med 2017. [PMID: 28646590 DOI: 10.1111/acem.13245] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVE Gastroparesis is a debilitating condition that causes nausea, vomiting, and abdominal pain. Management includes analgesics and antiemetics, but symptoms are often refractory. Haloperidol has been utilized in the palliative care setting for similar symptoms. The study objective was to determine whether haloperidol as an adjunct to conventional therapy would improve symptoms in gastroparesis patients presenting to the emergency department (ED). STUDY DESIGN AND METHODS This was a randomized, double-blind, placebo-controlled trial of adult ED patients with acute exacerbation of previously diagnosed gastroparesis. The treatment group received 5 mg of haloperidol plus conventional therapy (determined by the treating physician). The control group received a placebo plus conventional therapy. The severity of each subject's abdominal pain and nausea were assessed before intervention and every 15 minutes thereafter for 1 hour using a 10-point scale for pain and a 5-point scale for nausea. Primary outcomes were decreased pain and nausea 1 hour after treatment. RESULTS Of the 33 study patients, 15 were randomized to receive haloperidol. Before treatment, the mean intensity of pain was 8.5 in the haloperidol group and 8.28 in the placebo group; mean pretreatment nausea scores were 4.53 and 4.11, respectively. One hour after therapy, the mean pain and nausea scores in the haloperidol group were 3.13 and 1.83 compared to 7.17 and 3.39 in the placebo group. The reduction in mean pain intensity therapy was 5.37 in the haloperidol group (p ≤ 0.001) compared to 1.11 in the placebo group (p = 0.11). The reduction in mean nausea score was 2.70 in the haloperidol group (p ≤ 0.001) and 0.72 in the placebo group (p = 0.05). Therefore, the reductions in symptom scores were statistically significant in the haloperidol group but not in the placebo group. No adverse events were reported. CONCLUSIONS Haloperidol as an adjunctive therapy is superior to placebo for acute gastroparesis symptoms.
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Affiliation(s)
- Carlos J. Roldan
- Department of Pain Medicine; The University of Texas MD Anderson Cancer Center; Houston TX
- Department of Emergency Medicine; McGovern Medical School; The University of Texas Health Science Center at Houston; Houston TX
- Memorial Hermann-Texas Medical Center; Houston TX
- Lyndon B. Johnson General Hospital; Houston TX
| | - Kimberly A. Chambers
- Department of Emergency Medicine; McGovern Medical School; The University of Texas Health Science Center at Houston; Houston TX
- Memorial Hermann-Texas Medical Center; Houston TX
- Lyndon B. Johnson General Hospital; Houston TX
| | - Linda Paniagua
- Department of Emergency Medicine; Valley Baptist Medical Center; Brownsville TX
| | - Sonali Patel
- Department of Emergency Medicine Methodist Hospital; Houston TX
- Conroe Regional Medical Center; Conroe TX
| | - Marylou Cardenas-Turanzas
- Department of Emergency Medicine; McGovern Medical School; The University of Texas Health Science Center at Houston; Houston TX
| | - Yashwant Chathampally
- Department of Emergency Medicine; McGovern Medical School; The University of Texas Health Science Center at Houston; Houston TX
- Memorial Hermann-Texas Medical Center; Houston TX
- Lyndon B. Johnson General Hospital; Houston TX
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Miksys S, Wadji FB, Tolledo EC, Remington G, Nobrega JN, Tyndale RF. Rat brain CYP2D enzymatic metabolism alters acute and chronic haloperidol side-effects by different mechanisms. Prog Neuropsychopharmacol Biol Psychiatry 2017; 78:140-148. [PMID: 28454738 DOI: 10.1016/j.pnpbp.2017.04.030] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2017] [Revised: 04/13/2017] [Accepted: 04/25/2017] [Indexed: 01/26/2023]
Abstract
Risk for side-effects after acute (e.g. parkinsonism) or chronic (e.g. tardive dyskinesia) treatment with antipsychotics, including haloperidol, varies substantially among people. CYP2D can metabolize many antipsychotics and variable brain CYP2D metabolism can influence local drug and metabolite levels sufficiently to alter behavioral responses. Here we investigated a role for brain CYP2D in acutely and chronically administered haloperidol levels and side-effects in a rat model. Rat brain, but not liver, CYP2D activity was irreversibly inhibited with intracerebral propranolol and/or induced by seven days of subcutaneous nicotine pre-treatment. The role of variable brain CYP2D was investigated in rat models of acute (catalepsy) and chronic (vacuous chewing movements, VCMs) haloperidol side-effects. Selective inhibition and induction of brain, but not liver, CYP2D decreased and increased catalepsy after acute haloperidol, respectively. Catalepsy correlated with brain, but not hepatic, CYP2D enzyme activity. Inhibition of brain CYP2D increased VCMs after chronic haloperidol; VCMs correlated with brain, but not hepatic, CYP2D activity, haloperidol levels and lipid peroxidation. Baseline measures, hepatic CYP2D activity and plasma haloperidol levels were unchanged by brain CYP2D manipulations. Variable rat brain CYP2D alters side-effects from acute and chronic haloperidol in opposite directions; catalepsy appears to be enhanced by a brain CYP2D-derived metabolite while the parent haloperidol likely causes VCMs. These data provide novel mechanistic evidence for brain CYP2D altering side-effects of haloperidol and other antipsychotics metabolized by CYP2D, suggesting that variation in human brain CYP2D may be a risk factor for antipsychotic side-effects.
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Affiliation(s)
- Sharon Miksys
- Centre for Addiction and Mental Health, Campbell Family Mental Health Research Institute, Toronto, Canada; Department of Pharmacology and Toxicology, University of Toronto, Canada.
| | | | - Edgor Cole Tolledo
- Centre for Addiction and Mental Health, Campbell Family Mental Health Research Institute, Toronto, Canada; Department of Pharmacology and Toxicology, University of Toronto, Canada.
| | - Gary Remington
- Centre for Addiction and Mental Health, Campbell Family Mental Health Research Institute, Toronto, Canada; Institute of Medical Science, University of Toronto, Canada; Department of Psychological Clinical Sciences, University of Toronto, Canada; Department of Psychiatry, University of Toronto, Canada.
| | - Jose N Nobrega
- Centre for Addiction and Mental Health, Campbell Family Mental Health Research Institute, Toronto, Canada; Department of Pharmacology and Toxicology, University of Toronto, Canada; Department of Psychiatry, University of Toronto, Canada; Department of Psychology, University of Toronto, Canada.
| | - Rachel F Tyndale
- Centre for Addiction and Mental Health, Campbell Family Mental Health Research Institute, Toronto, Canada; Department of Pharmacology and Toxicology, University of Toronto, Canada; Department of Psychiatry, University of Toronto, Canada.
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Understanding migraine as a cycling brain syndrome: reviewing the evidence from functional imaging. Neurol Sci 2017; 38:125-130. [DOI: 10.1007/s10072-017-2866-0] [Citation(s) in RCA: 54] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
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Fisher H. Comment on a Randomized Controlled Trial of Intravenous Haloperidol versus Intravenous Metoclopramide for Acute Migraine Therapy in the Emergency Department. J Emerg Med 2017; 52:e75. [PMID: 27856026 DOI: 10.1016/j.jemermed.2016.03.041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2016] [Accepted: 03/25/2016] [Indexed: 06/06/2023]
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Affiliation(s)
- Benjamin W Friedman
- Department of Emergency Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY.
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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; 56:911-40. [DOI: 10.1111/head.12835] [Citation(s) in RCA: 132] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2016] [Accepted: 04/13/2016] [Indexed: 12/26/2022]
Affiliation(s)
| | | | | | - Mia T. Minen
- New York University Langone Medical Center; New York NY USA
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Review of the Typical and Atypical Treatment Options for Acute Migraine Headache in the Emergency Department. CURRENT EMERGENCY AND HOSPITAL MEDICINE REPORTS 2016. [DOI: 10.1007/s40138-016-0099-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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