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Robblee J, Zhao XR, Minen MT, Friedman BW, Cortel-LeBlanc MA, Cortel-LeBlanc A, Orr SL. The 2023 protocol for update to acute treatment of adults with migraine in the emergency department: The American Headache Society evidence assessment of parenteral pharmacotherapies. Headache 2024; 64:869-872. [PMID: 38828836 DOI: 10.1111/head.14744] [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: 11/10/2023] [Revised: 05/03/2024] [Accepted: 05/07/2024] [Indexed: 06/05/2024]
Abstract
OBJECTIVES The primary objective of this proposed guideline is to update the prior 2016 guideline on parenteral pharmacotherapies for the management of adults with a migraine attack in the emergency department (ED). METHODS We will conduct an updated systematic review and meta-analysis using the 2016 guideline methodology to provide clinical recommendations. The same search strategy will be used for studies up to 2023, with a new search strategy added to capture studies of nerve blocks and sphenopalatine blocks. Medline, Embase, Cochrane, clinicaltrials.gov, and the World Health Organization International Clinical Trial Registry Platform will be searched. Our inclusion criteria consist of studies involving adults with a diagnosis of migraine, utilizing medications administered intravenously, intramuscularly, or subcutaneously in a randomized controlled trial design. Two authors will perform the selection of studies based on title and abstract, followed by a full-text review. A third author will intervene in cases of disagreements. Data will be recorded in a standardized worksheet and subjected to verification. The risk of bias will be assessed using the American Academy of Neurology tool. When applicable, a meta-analysis will be conducted. The efficacy of medications will be evaluated, categorizing them as "highly likely," "likely", or "possibly effective" or "ineffective." Subsequently, clinical recommendations will be developed, considering the risk associated with the medications, following the American Academy of Neurology recommendation development process. RESULTS The goal of this updated guideline will be to provide guidance on which injectable medications, including interventional approaches (i.e., nerve blocks, sphenopalatine ganglion), should be considered effective acute treatment for adults with migraine who present to an ED. CONCLUSIONS The methods outlined in this protocol will be used in the design of a future systematic review and meta-analysis-informed guideline, which will then be assessed by and submitted for endorsement by the American Headache Society.
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Affiliation(s)
- Jennifer Robblee
- Lewis Headache Clinic, Department of Neurology, Barrow Neurological Institute, Dignity Health, Phoenix, Arizona, USA
| | - Xurong Rachel Zhao
- Alberta Health Services, Alberta's Children Hospital, Calgary, Alberta, Canada
| | - Mia T Minen
- Department of Neurology, NYU Langone Health, New York, New York, USA
- Department Population Health, NYU Langone Health, New York, New York, USA
| | - Benjamin W Friedman
- Department of Emergency Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Miguel A Cortel-LeBlanc
- Department of Emergency Medicine, Queensway Carleton Hospital, Ottawa, Ontario, Canada
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
- Institut du Savoir Montfort, Ottawa, Ontario, Canada
- 360 Concussion Care, Ottawa, Ontario, Canada
| | - Achelle Cortel-LeBlanc
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
- Institut du Savoir Montfort, Ottawa, Ontario, Canada
- 360 Concussion Care, Ottawa, Ontario, Canada
- Division of Neurology, Queensway Carleton Hospital, Ottawa, Ontario, Canada
| | - Serena L Orr
- Department of Pediatrics, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Division of Neurology, Alberta Children's Hospital, Calgary, 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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Goenka A, Chikkannaiah M, Fonseca LD, Kumar G. Peripheral Nerve Blocks: A Tool for Inpatient Pediatric Status Migrainosus. Pediatr Neurol 2023; 138:81-86. [PMID: 36423569 DOI: 10.1016/j.pediatrneurol.2022.10.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Revised: 08/23/2022] [Accepted: 10/25/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND To assess the efficacy and safety of peripheral nerve blocks in the inpatient settings for pediatric patients presenting with status migrainosus. METHODS An analysis of a retrospective cohort of patients aged 13 to 18 years, admitted for status migrainosus from 2017 to 2022, was performed. Among the 1805 patients who presented with status migrainosus, 265 required hospital admission. A total of 177 patients failed the first- and second-line intravenous therapy and were treated with either peripheral nerve block (PNB) or dihydroergotamine (DHE) intravenous infusions. The primary outcome of the study was pain score level reduction by 50%, and the secondary outcome was duration of hospital stay. Visual analog scale score was used for pain assessment. RESULTS Among the 177 patients, 100 patients were treated with DHE and 77 were treated with PNB. Target pain control was achieved in 59 of 100 patients receiving DHE and 38 of 77 patients receiving PNB. The average hospital stay of patients who responded to PNB was significantly lower compared with that of patients receiving DHE (3.6 days vs 4.9 days). Among the 41 patients who were refractory to DHE, 30 patients received PNB, of which 12 responded to nerve blocks. The most common side effects for PNBs were pain at injection site in 39% of patients and nausea/vomiting for DHE in 50% of patients. CONCLUSIONS PNB can be safely administered in the hospital setting to pediatric patients with status migrainosus. PNB treatment helped achieve target pain control with minimal side effects and reduced the hospital stay duration.
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Affiliation(s)
- Ajay Goenka
- Department of Neurology, Dayton Children's Hospital, Dayton, Ohio; Department of Pediatrics, Wright State University Boonshoft School of Medicine, Dayton, Ohio
| | - Mahesh Chikkannaiah
- Department of Neurology, Dayton Children's Hospital, Dayton, Ohio; Department of Pediatrics, Wright State University Boonshoft School of Medicine, Dayton, Ohio
| | - Laura D Fonseca
- Department of Neurology, Dayton Children's Hospital, Dayton, Ohio.
| | - Gogi Kumar
- Department of Neurology, Dayton Children's Hospital, Dayton, Ohio; Department of Pediatrics, Wright State University Boonshoft School of Medicine, Dayton, Ohio
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Schwedt TJ, Tassorelli C, Silberstein SD, Szperka CL, Kurth T, Pozo-Rosich P, Amin FM, Lipton RB, Dodick DW, Ashina M, Diener HC, Terwindt GM. Guidelines of the International Headache Society for Clinic-Based Headache Registries, 1 st edition. Cephalalgia 2022; 42:1099-1115. [PMID: 35514209 PMCID: PMC10141527 DOI: 10.1177/03331024221099035] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Clinic-based headache registries collect data for a wide variety of purposes including delineating disease characteristics, longitudinal natural disease courses, headache management approaches, quality of care, treatment safety and effectiveness, factors that predict treatment response, health care resource utilization, clinician adherence to guidelines, and cost-effectiveness. Registry data are valuable for numerous stakeholders, including individuals with headache disorders and their caregivers, healthcare providers, scientists, healthcare systems, regulatory authorities, pharmaceutical companies, employers, and policymakers. This International Headache Society document may serve as guidance for developing clinic-based headache registries. Use of registry data requires a formal research protocol that includes: 1) research aims; 2) methods for data collection, harmonization, analysis, privacy, and protection; 3) methods for human subject protection; and 4) publication and dissemination plans. Depending upon their objectives, headache registries should include validated headache-specific questionnaires, patient reported outcome measures, data elements that are used consistently across studies (i.e., "common data elements"), and medical record data. Amongst other data types, registries may be linked to healthcare and pharmacy claims data, biospecimens, and neuroimaging data. Headache diagnoses should be made according to the International Classification of Headache Disorders diagnostic criteria. The data from well-designed headache registries can provide wide-ranging and novel insights into the characteristics, burden, and treatment of headache disorders and ultimately lead to improvements in the management of patients with headache.
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Affiliation(s)
| | - Cristina Tassorelli
- Headache Science & Neurorehabilitation Unit, National Neurological Institute C. Mondino Foundation, Pavia, Italy
- Dept. of Brain and Behavioral Sciences, University of Pavia, Pavia (I)
| | | | - Christina L. Szperka
- Division of Neurology, Children’s Hospital of Philadelphia & Department of Neurology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Tobias Kurth
- Institute of Public Health, Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Patricia Pozo-Rosich
- Headache Unit, Neurology Department, Vall d’Hebron University Hospital & Headache Research Group, Vall d’Hebron Research Institute, Universitat Autonoma de Barcelona, Barcelona, Spain
| | - Faisal Mohammad Amin
- Danish Headache Center, Department of Neurology, Rigshospitalet Glostrup, Faculty of Health and Medical Sciences, University of Copenhagen, Glostrup, Denmark
- Department of Neurorehabilitation/Traumatic Brain Injury, Rigshospitalet, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Richard B. Lipton
- Department of Neurology, Department of Epidemiology and Population Health, Department of Psychiatry and Behavioral Sciences, Albert Einstein College of Medicine, Bronx, New York, USA
| | | | - Messoud Ashina
- Danish Headache Center, Department of Neurology, Rigshospitalet Glostrup, Faculty of Health and Medical Sciences, University of Copenhagen, Glostrup, Denmark
| | - Hans-Christoph Diener
- Institute for Medical Informatics, Biometry and Epidemiology, University Duisburg-Essen, Essen, Germany
| | - Gisela M. Terwindt
- Department of Neurology, Leiden University Medical Center, Leiden, The Netherlands
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Richer LP, Ali S, Johnson DW, Rosychuk R, Newton AS, Rowe BH. A randomized trial of ketorolac and metoclopramide for migraine in the emergency department. Headache 2022; 62:681-689. [DOI: 10.1111/head.14307] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2021] [Accepted: 03/24/2022] [Indexed: 11/28/2022]
Affiliation(s)
- Lawrence P. Richer
- Department of Pediatrics Faculty of Medicine & Dentistry University of Alberta Edmonton Alberta Canada
- Women and Children’s Health Research Institute, Faculty of Medicine & Dentistry University of Alberta Edmonton Alberta Canada
| | - Samina Ali
- Department of Pediatrics Faculty of Medicine & Dentistry University of Alberta Edmonton Alberta Canada
- Women and Children’s Health Research Institute, Faculty of Medicine & Dentistry University of Alberta Edmonton Alberta Canada
- Department of Emergency Medicine Faculty of Medicine & Dentistry University of Alberta Edmonton Alberta Canada
| | - David W. Johnson
- Department of Pediatrics Emergency Medicine, and Physiology and Pharmacology University of Calgary Calgary Alberta Canada
| | - Rhonda J. Rosychuk
- Department of Pediatrics Faculty of Medicine & Dentistry University of Alberta Edmonton Alberta Canada
- Women and Children’s Health Research Institute, Faculty of Medicine & Dentistry University of Alberta Edmonton Alberta Canada
| | - Amanda S. Newton
- Department of Pediatrics Faculty of Medicine & Dentistry University of Alberta Edmonton Alberta Canada
- Women and Children’s Health Research Institute, Faculty of Medicine & Dentistry University of Alberta Edmonton Alberta Canada
| | - Brian H. Rowe
- Women and Children’s Health Research Institute, Faculty of Medicine & Dentistry University of Alberta Edmonton Alberta Canada
- Department of Emergency Medicine Faculty of Medicine & Dentistry University of Alberta Edmonton Alberta Canada
- School of Public Health University of Alberta Edmonton Alberta Canada
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Friedman BW, Irizarry E, Feliciano C, Izzo AJ, Borrayes L, Restivo A, Costa V, Bijur PE. A randomized controlled trial of oxycodone/acetaminophen versus acetaminophen alone for emergency department patients with musculoskeletal pain refractory to ibuprofen. Acad Emerg Med 2021; 28:859-865. [PMID: 33576545 DOI: 10.1111/acem.14231] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Revised: 02/07/2021] [Accepted: 02/09/2021] [Indexed: 12/15/2022]
Abstract
BACKGROUND Use of oral opioids does not result in more pain relief than nonopioid alternatives when administered to patients as first-line treatment for acute musculoskeletal pain. This study compared the efficacy of oxycodone/acetaminophen to that of acetaminophen alone as second-line treatment for patients with acute musculoskeletal pain who were administered prescription-strength ibuprofen and reported insufficient relief 1 h later. METHODS A randomized, double-blind study was conducted in two urban emergency departments. Opioid-naïve patients ≥ 18 years with an acute musculoskeletal injury were administered ibuprofen 600 mg as part of the study protocol. Those who reported insufficient relief 1 h later were randomized (1:1 ratio) to oxycodone 10 mg/acetaminophen 650 mg or acetaminophen 650 mg. The primary outcome was improvement in 0 to 10 pain scale between randomization and 2 h later. We also assessed medication-associated adverse events. A sample size calculation, built around a minimum clinically important difference of 1.3 units, determined the need for 154 patients. RESULTS We screened 924 patients and enrolled 393. All 393 received ibuprofen. A total of 159 (40%) patients reported inadequate relief after 1 h had elapsed. A total of 154 of these were randomized, 77 to oxycodone/acetaminophen and 77 to acetaminophen. Baseline characteristics were comparable. Among patients randomized to oxycodone/acetaminophen, mean (±SD) improvement in 0 to 10 pain scale was 4.0 (±2.6) versus 2.9 (±2.4) in the acetaminophen arm. The 95% confidence interval (CI) for the mean difference of 1.1 was 0.3 to 1.9. Among patients who received oxycodone/acetaminophen, 26 of 76 (34%) reported any medication-related adverse event versus seven of 74 (9%) participants who received acetaminophen. The 95% CI for the between-group difference of 25% was 12% to 37%). CONCLUSION Among patients with acute musculoskeletal pain refractory to oral ibuprofen, oxycodone/acetaminophen resulted in slightly greater pain relief than acetaminophen, but this was associated with more medication-related adverse events.
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Affiliation(s)
- Benjamin W. Friedman
- Department of Emergency Medicine Albert Einstein College of MedicineMontefiore Medical Center Bronx New York USA
| | - Eddie Irizarry
- Department of Emergency Medicine Albert Einstein College of MedicineMontefiore Medical Center Bronx New York USA
| | - Carmen Feliciano
- Department of Emergency Medicine Albert Einstein College of MedicineMontefiore Medical Center Bronx New York USA
| | - Albert J. Izzo
- Department of Emergency Medicine Albert Einstein College of MedicineMontefiore Medical Center Bronx New York USA
| | - Lester Borrayes
- Department of Emergency Medicine Albert Einstein College of MedicineMontefiore Medical Center Bronx New York USA
| | - Andrew Restivo
- Department of Emergency Medicine Albert Einstein College of MedicineMontefiore Medical Center Bronx New York USA
| | - Vincent Costa
- Department of Emergency Medicine Albert Einstein College of MedicineMontefiore Medical Center Bronx New York USA
| | - Polly E. Bijur
- Department of Emergency Medicine Albert Einstein College of MedicineMontefiore Medical Center Bronx New York USA
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Hokenek NM, Ozer D, Yılmaz E, Baskaya N, Hokenek UD, Ak R, Guven R, Erdogan MO, Mepham LA. Comparison of greater occipital nerve and supra orbital nerve blocks methods in the treatment of acute migraine attack: A randomized double-blind controlled trial. Clin Neurol Neurosurg 2021; 207:106821. [PMID: 34304069 DOI: 10.1016/j.clineuro.2021.106821] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Revised: 07/07/2021] [Accepted: 07/08/2021] [Indexed: 01/03/2023]
Abstract
OBJECTIVE The main goal of this investigation is to compare the Greater Occipital Nerve (GON) and Supra Orbital Nerve (SON) block methods used in the treatment of migraine attacks in the ED with each other, in combination, and with a placebo. METHODS This study was planned as a single center, prospective, double-blind, randomized control study. The patients were divided into 4 groups: GON, SON, Combined, and Placebo. Groups were named according to the nerve areas that were blocked. Therefore1% lidocaine for nerve blockade and 0.9% NaCl for placebo effect was used. Along with the time of admission, baseline pain scale values, as well as recordings at 30 and 60 min in addition to the Visual Analog Scale (VAS) at the 120th min. and Likert-Type (LT) Verbal scale at the 120th min. were measured. The primary outcome of this study was a change in the VAS and LT values at the 0-120th minute after treatment RESULTS: In this study, 128 patients in 4 groups were included in the analysis. In the GON group, SON group, and Combined group, the change observed at the 120th minute scores compared to baseline VAS scores was higher than Placebo group [OR (95% CI) = -17.4 (-24.8, -9.9), 32.1 (23.8, 40.3), 49.5 (41.9, 57), respectively]. In inter-group comparison, it was found that the VAS and LT scores of the Combined group and the GON group improved at a higher rate than the SON group CONCLUSIONS: SON blockade, GON blockade, and a combination of these two blockades are effective treatment methods in acute migraine attack. Performing a GON or Combined blockade for migraine attack causes greater pain reduction than SON blockade.
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Affiliation(s)
- Nihat M Hokenek
- Department of Emergency Medicine, University of Health Sciences, Kartal Dr. Lütfi Kırdar City Hospital, İstanbul, Turkey.
| | - Duygu Ozer
- Department of Neurology, University of Health Sciences, Kartal Dr. Lütfi Kırdar City Hospital, İstanbul, Turkey
| | - Erdal Yılmaz
- Department of Emergency Medicine, University of Health Sciences, Kartal Dr. Lütfi Kırdar City Hospital, İstanbul, Turkey
| | - Nurhayat Baskaya
- Department of Emergency Medicine, University of Health Sciences, Kartal Dr. Lütfi Kırdar City Hospital, İstanbul, Turkey
| | - Ummahan Dalkilinc Hokenek
- Department of Anesthesiology and Reanimation, University of Health Sciences, Kartal Dr. Lütfi Kırdar City Hospital, İstanbul, Turkey
| | - Rohat Ak
- Department of Emergency Medicine, University of Health Sciences, Kartal Dr. Lütfi Kırdar City Hospital, İstanbul, Turkey
| | - Ramazan Guven
- Department of Emergency Medicine, Basaksehir Cam ve Sakura Hospital, İstanbul, Turkey
| | - Mehmet O Erdogan
- Department of Emergency Medicine, University of Health Sciences, Bakırköy Dr. Sadi Konuk Training and Research Hospital, İstanbul, Turkey
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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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Hodgson SE, Harding AM, Bourke EM, Taylor DM, Greene SL. A prospective, randomized, double-blind trial of intravenous chlorpromazine versus intravenous prochlorperazine for the treatment of acute migraine in adults presenting to the emergency department. Headache 2021; 61:603-611. [PMID: 33797074 DOI: 10.1111/head.14091] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2020] [Revised: 01/27/2021] [Accepted: 02/12/2021] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To compare the efficacy of intravenous chlorpromazine versus intravenous prochlorperazine for the treatment of acute migraine in adults presenting to the emergency department (ED). BACKGROUND Migraine is a common, incapacitating neurological condition. Although chlorpromazine and prochlorperazine are known to be safe, efficacious treatments for migraine, they have never been directly compared. DESIGN We performed a prospective, randomized, double-blind clinical trial at a tertiary hospital in Melbourne, Australia. Adults aged 18-65 years, who presented with migraine, were eligible for recruitment. Sixty-six patients were randomized to either chlorpromazine 12.5 mg or prochlorperazine 12.5 mg, both infused in 500 ml of sodium chloride 0.9% over 30 min. Headache severity score, nausea severity score, and the presence of photophobia and phonophobia were assessed at 0, 30, 60, and 120 min. Adverse effects and the need for rescue therapy were recorded. The primary outcome was a reduction in headache severity score from baseline at 60 min post-commencement of the study medicine infusion. RESULTS Sixty-five patients were included in the analysis. There was a median reduction in headache severity score at 60 min of 3.0 (interquartile range 1.0-4.0) in the chlorpromazine arm versus 2.0 (1.0-4.0) in the prochlorperazine arm (median difference -0.5 (95% confidence interval, -1.9 to 0.9)). We saw no evidence of a difference in secondary outcomes at 30, 60, or 120 min. Side effects were reported in 16/32 (50%) patients in the chlorpromazine group versus 7/33 (21%) in the prochlorperazine group (p = 0.020). Rescue therapy was required in 7/32 (22%) patients in the chlorpromazine group versus 12/33 (36%) in the prochlorperazine group (p = 0.277). CONCLUSIONS Both chlorpromazine and prochlorperazine are efficacious treatments for acute migraine in adult patients presenting to the ED. This trial found no evidence of superiority of either agent over the other. Caution should be used when prescribing these medicines in the borderline hypotensive patient; in that circumstance, prochlorperazine should be preferentially used.
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Affiliation(s)
- Sarah E Hodgson
- Emergency Department, Austin Health, Melbourne, VIC, Australia
| | - Andrew M Harding
- Emergency Department, Austin Health, Melbourne, VIC, Australia.,Pharmacy Department, Austin Health, Melbourne, VIC, Australia
| | | | - David M Taylor
- Emergency Department, Austin Health, Melbourne, VIC, Australia.,Department of Medicine and Radiology, University of Melbourne, Parkville, VIC, Australia
| | - Shaun L Greene
- Emergency Department, Austin Health, Melbourne, VIC, Australia.,Victorian Poisons Information Centre, Austin Health, Melbourne, VIC, Australia
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Swart ECS, Good CB, Henderson R, Manolis C, Yanta C, Parekh N, Neilson LM. Identifying Outcome Measures for Migraine Value-Based Contracting Using the Delphi Method. Headache 2020; 60:2139-2151. [PMID: 32997806 DOI: 10.1111/head.13978] [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: 06/12/2020] [Revised: 08/05/2020] [Accepted: 08/06/2020] [Indexed: 01/07/2023]
Abstract
OBJECTIVE To identify meaningful migraine outcome measures among key stakeholders to inform value-based contracts for migraine medications. BACKGROUND Value-based contracts linking medication payments to predefined performance metrics aim to promote value through aligned incentives and shared risk between manufacturers and payers. The emergence of new and expensive pharmaceuticals for migraine presents an opportunity for value-based contract development. However, uncertainty remains around which outcomes are most meaningful to all migraine stakeholders. METHODS This study utilized a Delphi survey to incorporate views from 82 stakeholders, including patients (n = 21), providers (n = 23), payers (n = 10), employers (n = 18), and pharmaceutical company representatives (n = 10). A list of 15 migraine-related outcomes was created from a literature review and subject matter expert consultation. Stakeholders reported on the value of these outcomes through a 5-point Likert scale and selection of their top 3 most meaningful outcomes. All participants except patients and employers also used a 5-point Likert scale to rate the feasibility of collecting each outcome measure. Consensus was defined as ≥75% agreement on the importance and feasibility of an outcome (Likert scores ≥4/5 or selection of an outcome as most meaningful). RESULTS After 2 rounds, consensus was achieved for importance of 9 outcomes on the Likert scale. "Decrease in migraine frequency" reached 100% agreement (82/82), followed by "increased ability to resume normal activities" (96%, 79/82). When asked to choose the 3 most meaningful outcomes, stakeholders selected "decrease in migraine frequency" (88%, 72/82) followed by "decrease in migraine severity" (80%, 66/82). The 2 measures rated as most feasibly collected were "decrease in emergency department/urgent care visits" (95%, 40/42) and "decrease in migraine frequency" (90%, 38/42). There were statistically significant differences between non-patient and patient stakeholders in selection of "decrease in emergency department/urgent care visits" [20% (12/61) vs 0% (0/21), P = .031]; and employer and patient stakeholders in selection of "decrease in work days missed" [44% (8/18) vs 5% (1/21), P = .006] and "decrease in emergency department/urgent care visits" [22% (4/18) vs 0% (0/21), P = .037] as most meaningful outcomes. CONCLUSIONS The measures "decrease in migraine frequency" followed by "decrease in migraine severity" were identified as top priority migraine outcome measures.
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Affiliation(s)
- Elizabeth C S Swart
- UPMC Centers for High-Value Health Care and Value-Based Pharmacy Initiatives, UPMC Health Plan, Pittsburgh, PA, USA
| | - Chester B Good
- UPMC Centers for High-Value Health Care and Value-Based Pharmacy Initiatives, UPMC Health Plan, Pittsburgh, PA, USA.,Division of General Internal Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | | | - Chronis Manolis
- UPMC Centers for High-Value Health Care and Value-Based Pharmacy Initiatives, UPMC Health Plan, Pittsburgh, PA, USA
| | - Claire Yanta
- Department of Neurology, University of Pittsburgh, Pittsburgh, PA, USA
| | | | - Lynn M Neilson
- UPMC Centers for High-Value Health Care and Value-Based Pharmacy Initiatives, UPMC Health Plan, Pittsburgh, PA, USA
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Friedman BW, Irizarry E, Williams A, Solorzano C, Zias E, Robbins MS, Harrilal MA, Del Valle M, Bijur PE, Gallagher EJ. A Randomized, Double-Dummy, Emergency Department-Based Study of Greater Occipital Nerve Block With Bupivacaine vs Intravenous Metoclopramide for Treatment of Migraine. Headache 2020; 60:2380-2388. [PMID: 32981043 DOI: 10.1111/head.13961] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Revised: 07/16/2020] [Accepted: 08/06/2020] [Indexed: 12/24/2022]
Abstract
BACKGROUND Greater occipital nerve blocks (GONB) are used increasingly to treat acute migraine. OBJECTIVE We conducted a randomized controlled trial to determine whether GONB was as effective as intravenous metoclopramide for migraine. METHODS This was a double-dummy, double-blind, parallel-arm, non-inferiority study conducted in 2 emergency departments (EDs). Patients with migraine of moderate or severe intensity were randomized to receive bilateral GONB with each side administered 3 mL of bupivacaine 0.5% or metoclopramide 10 mg IV, the putative standard of care. The primary outcome was improvement in pain on a 0-10 scale between time 0 and 1 hour later. To reject the null hypothesis that metoclopramide would be more efficacious in relieving pain, we required that the lower limit of the 95% CI for the difference in pain improvement between those randomized to GONB vs those randomized to metoclopramide be >-1.3, a validated minimum clinically important difference. Secondary outcomes included sustained headache relief, defined as achieving and maintaining for 48 hours a headache level of mild or none without the use of additional analgesic medication, and the use of rescue medication in the ED. RESULTS Over a 2.5-year study period, 1358 patients were screened for participation and 99 were randomized, 51 to GONB and 48 to metoclopramide. All of these patients were included in the primary analysis. Patients who received the GONB reported mean improvement of 5.0 (95% CI: 4.1, 5.8) while those who received metoclopramide reported a larger mean improvement of 6.1 (95% CI: 5.2, 6.9). The 95% CI for the between group difference of -1.1 was -2.3, 0.1. Sustained headache relief was reported by 11/51 (22%) GONB and 18/47 (38%) metoclopramide patients (95% CI for rounded difference of 17%: -1, 35%). Of the 51 GONB patients, 17 (33%) required rescue medication in the ED vs 8/48 (17%) metoclopramide patients (95% CI for rounded difference of 17%: 0, 33%). An adverse event was reported by 16/51 (31%) GONB patients and 18/48 (38%) metoclopramide patients (95% CI for (rounded) difference of 6%: -13, 25%). CONCLUSION GONB with bupivacaine was not as efficacious as IV metoclopramide for the first-line treatment of migraine in the ED.
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Affiliation(s)
- Benjamin W Friedman
- Department of Emergency Medicine, Albert Einstein College of Medicine, Montefiore, Bronx, NY, USA
| | - Eddie Irizarry
- Department of Emergency Medicine, Albert Einstein College of Medicine, Montefiore, Bronx, NY, USA
| | - Andrew Williams
- Department of Emergency Medicine, Albert Einstein College of Medicine, Montefiore, Bronx, NY, USA
| | | | | | - Matthew S Robbins
- Department of Neurology, Weill Cornell Medicine, New York-Presbyterian, New York, NY, USA
| | - Melissa A Harrilal
- Department of Emergency Medicine, Albert Einstein College of Medicine, Montefiore, Bronx, NY, USA
| | - Michael Del Valle
- Department of Emergency Medicine, Albert Einstein College of Medicine, Montefiore, Bronx, NY, USA
| | - Polly E Bijur
- Department of Emergency Medicine, Albert Einstein College of Medicine, Montefiore, Bronx, NY, USA
| | - E John Gallagher
- Department of Emergency Medicine, Albert Einstein College of Medicine, Montefiore, Bronx, NY, USA.,Department of Neurology, Albert Einstein College of Medicine, Montefiore, Bronx, NY, USA
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Chi PW, Hsieh KY, Chen KY, Hsu CW, Bai CH, Chen C, Hsu YP. Intranasal lidocaine for acute migraine: A meta-analysis of randomized controlled trials. PLoS One 2019; 14:e0224285. [PMID: 31644605 PMCID: PMC6808552 DOI: 10.1371/journal.pone.0224285] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2019] [Accepted: 10/09/2019] [Indexed: 11/18/2022] Open
Abstract
Background Intranasal lidocaine has been shown to be effective in treating patients with acute migraines; however, its efficacy is still controversial. In this study, we intend to assess the efficacy and safety of intranasal lidocaine compared with a placebo or an active comparator for the treatment of migraines. Method PubMed, EMBASE, Cochrane library, and Scopus databases were searched from their inceptions to November 2018. Randomized controlled studies investigating the efficacy of intranasal lidocaine compared with a placebo or an active comparator were selected. Two reviewers independently extracted and synthesized data using a random-effects model. The primary outcome was pain intensity. The secondary outcomes were success rate, the need for rescue medicine, and relapse occurrences. We registered the study at PROSPERO with an ID of CRD42018116226. Results Six studies (n = 613) were eligible for the meta-analysis. Overall, the results revealed that the study population who was administered intranasal lidocaine had a lower pain intensity at 5 min (standardized mean difference (SMD) = -0.61; 95% CI = -1.04 to -0.19) and 15 min (SMD = -0.72; 95% CI = -1.14 to -0.19), had a higher success rate (RR = 3.55; 95% CI: 1.89 to 6.64) and a less frequent need for rescue medicine (RR = 0.51; 95% CI = 0.36 to 0.72) than the control group. These beneficial effects were not observed when an antiemetic was administered. Furthermore, intranasal lidocaine use had no significant influence on the relapse rate (RR = 0.89; 95% CI = 0.51–1.56), regardless of the use of antiemetics. Using lidocaine caused local irritation in up to 49.4% of the patients in one report but did not cause major adverse events. Conclusion Intranasal lidocaine can be considered a useful option for patients with an acute migraine. It yields a high success rate, a low pain intensity, an infrequent need for rescue medicine, and tolerable adverse events. The administration of antiemetics is an important confounding factor.
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Affiliation(s)
- Pei-Wen Chi
- Emergency Department, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
- Department of Emergency, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Kun-Yi Hsieh
- Emergency Department, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
- Department of Emergency, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Kuan-Yu Chen
- Department of Medical Education, National Taiwan University Hospital, Taipei, Taiwan
| | - Chin-Wang Hsu
- Emergency Department, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
- Department of Emergency, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Chyi-Huey Bai
- Department of Public Health, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Chiehfeng Chen
- Department of Public Health, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
- Cochrane Taiwan, Taipei Medical University, Taipei, Taiwan
- Division of Plastic Surgery, Department of Surgery, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
- Evidence-based Medicine Center, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
| | - Yuan-Pin Hsu
- Emergency Department, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
- Department of Emergency, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
- Research Center of Big Data and Meta-Analysis, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
- * E-mail:
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Chi PW, Hsieh KY, Tsai CW, Hsu CW, Bai CH, Chen C, Hsu YP. Intranasal lidocaine for acute migraine: A protocol for the systematic review of randomized clinical trials. Medicine (Baltimore) 2019; 98:e15699. [PMID: 31096514 PMCID: PMC6531246 DOI: 10.1097/md.0000000000015699] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Intranasal lidocaine has been shown to be effective in treating patients with acute migraines; however, its efficacy is still controversial. The aim of our study is to assess the efficacy and safety of intranasal lidocaine compared with a placebo or an active comparator for the treatment of acute migraine. METHODS We will use PubMed, EMBASE, Cochrane library, and Scopus databases to search for articles from their inceptions to November 2018. We will only include randomized controlled studies. Data were independently will be extracted by 2 reviewers. Data analysis and synthesis will be analyzed by the Revman 5.3 software. We will conduct the study in accordance with the guideline of the Preferred Reporting Items for Systematic Review and Meta-analysis Protocols. RESULTS This review will evaluate the efficacy and safety of intranasal lidocaine for acute migraine. The primary outcome is pain intensity measured by visual analogue, numerical rating scale, or verbal rating scale. Secondary outcomes are success rate, requirement of rescue medicine, relapse, and adverse events. CONCLUSION The findings of this systematic review will summarize the latest evidence of intranasal lidocaine for acute migraine. The results will provide implications for clinical practice and further research.Prospero registration number: CRD42018116226.
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Affiliation(s)
| | | | | | | | - Chyi-Huey Bai
- Department of Public Health, School of Medicine, College of Medicine
| | - Chiehfeng Chen
- Department of Public Health, School of Medicine, College of Medicine
- Cochrane Taiwan
- Division of Plastic Surgery, Department of Surgery
- Evidence-based Medicine Center, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
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Latev A, Friedman BW, Irizarry E, Solorzano C, Restivo A, Chertoff A, Zias E, Gallagher EJ. A Randomized Trial of a Long-Acting Depot Corticosteroid Versus Dexamethasone to Prevent Headache Recurrence Among Patients With Acute Migraine Who Are Discharged From an Emergency Department. Ann Emerg Med 2018; 73:141-149. [PMID: 30449536 DOI: 10.1016/j.annemergmed.2018.09.028] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2018] [Revised: 09/04/2018] [Accepted: 09/25/2018] [Indexed: 01/03/2023]
Abstract
STUDY OBJECTIVE Migraine patients continue to report headache during the days and weeks after emergency department (ED) discharge. Dexamethasone is an evidence-based treatment of acute migraine that decreases the frequency of moderate or severe headache within 72 hours of ED discharge. We hypothesize that intramuscular methylprednisolone acetate, a long-acting steroid that remains biologically active for 14 days, will decrease the number of days with headache during the week after ED discharge by at least 1 day compared with intramuscular dexamethasone. METHODS We conducted a randomized, blinded clinical trial comparing intravenous metoclopramide at 10 mg+intramuscular dexamethasone at 10 mg with intravenous metoclopramide at 10 mg+intramuscular methylprednisolone acetate at a dose of 160 mg for patients presenting to 2 different EDs with moderate or severe migraine. Outcomes were assessed by telephone with a standardized instrument. The primary outcome was number of days with headache during the week after ED discharge. Secondary outcomes were complete freedom from headache, without the necessity of additional headache medication for the entire week after ED discharge, and medication preference, as determined by asking the patient whether he or she would want to receive the same medication again. RESULTS One hundred nine patients received dexamethasone and 111 received methylprednisolone acetate. We obtained primary outcome data from 101 dexamethasone patients and 106 methylprednisolone acetate patients. Dexamethasone patients reported 3.0 headache days and methylprednisolone acetate 3.3 headache days (95% confidence interval for rounded mean difference of 0.4 days: -0.4 to 1.1). Of 107 dexamethasone patients with analyzable data, 10 (9%) reported complete freedom from headache at 1 week versus 6 of 110 (5%) methylprednisolone acetate patients (95% confidence interval for difference of 4%: -3% to 11%). In the dexamethasone group, 76 of 101 (75%) patients would want the same medication again versus 75 of 106 (71%) of methylprednisolone acetate patients (95% confidence interval for difference of 4%: -8% to 17%). Other than injection site reactions, which were more common in the methylprednisolone acetate group, there were no substantial differences in frequency of adverse events. CONCLUSION Methylprednisolone acetate does not decrease the frequency of post-ED discharge headache days compared with dexamethasone. Most migraine patients are likely to continue to experience headache during the week after ED discharge.
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Affiliation(s)
- Alexander Latev
- Department of Emergency Medicine, Bronx, NY; Montefiore Health, Bronx, NY.
| | | | - Eddie Irizarry
- Department of Emergency Medicine, Bronx, NY; Montefiore Health, Bronx, NY
| | | | | | - Andrew Chertoff
- Department of Emergency Medicine, Bronx, NY; Montefiore Health, Bronx, NY
| | | | - E John Gallagher
- Department of Emergency Medicine, Bronx, NY; Montefiore Health, Bronx, NY
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Friedman BW, Mohamed S, Robbins MS, Irizarry E, Tarsia V, Pearlman S, John Gallagher E. A Randomized, Sham-Controlled Trial of Bilateral Greater Occipital Nerve Blocks With Bupivacaine for Acute Migraine Patients Refractory to Standard Emergency Department Treatment With Metoclopramide. Headache 2018; 58:1427-1434. [DOI: 10.1111/head.13395] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2018] [Revised: 06/07/2018] [Accepted: 06/19/2018] [Indexed: 12/18/2022]
Affiliation(s)
- Benjamin W. Friedman
- Department of Emergency Medicine; Albert Einstein College of Medicine, Montefiore Health System; Bronx NY USA
- Department of Physician Assistant Studies; York College, City University of New York; Jamaica NY
| | - Sajid Mohamed
- Department of Emergency Medicine; Albert Einstein College of Medicine, Montefiore Health System; Bronx NY USA
| | - Matthew S. Robbins
- Department of Neurology; Montefiore Headache Center; Albert Einstein College of Medicine; Montefiore Health System; Bronx NY USA
| | - Eddie Irizarry
- Department of Emergency Medicine; Albert Einstein College of Medicine, Montefiore Health System; Bronx NY USA
| | - Valerie Tarsia
- Department of Emergency Medicine; Albert Einstein College of Medicine, Montefiore Health System; Bronx NY USA
| | - Scott Pearlman
- Department of Emergency Medicine; Albert Einstein College of Medicine, Montefiore Health System; Bronx NY USA
| | - E. John Gallagher
- Department of Emergency Medicine; Albert Einstein College of Medicine, Montefiore Health System; Bronx NY USA
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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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Friedman BW, Irizarry E, Solorzano C, Latev A, Rosa K, Zias E, Vinson DR, Bijur PE, Gallagher EJ. Randomized study of IV prochlorperazine plus diphenhydramine vs IV hydromorphone for migraine. Neurology 2017; 89:2075-2082. [PMID: 29046364 DOI: 10.1212/wnl.0000000000004642] [Citation(s) in RCA: 49] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2017] [Accepted: 08/30/2017] [Indexed: 01/03/2023] Open
Abstract
OBJECTIVE To determine outcomes among patients with migraine in the emergency department (ED) who receive IV hydromorphone vs IV prochlorperazine + diphenhydramine. METHODS This study was conducted in 2 EDs in New York City. Patients who met international criteria for migraine were eligible for participation if they had not used an opioid within the previous month. Clinicians, participants, investigators, and research personnel were blinded to treatment. Patients were randomized in blocks of 4. Participants received hydromorphone 1 mg or prochlorperazine 10 mg + diphenhydramine 25 mg. Diphenhydramine was administered to prevent akathisia, a common side effect of IV prochlorperazine. The primary outcome was sustained headache relief, defined as achieving a headache level of mild or none within 2 hours of medication administration and maintaining that level for 48 hours without the requirement of rescue medication. A planned interim analysis was conducted once 48-hour data were available for 120 patients. RESULTS The trial was halted by the data monitoring committee after 127 patients had been enrolled. The primary outcome was achieved in the prochlorperazine arm by 37 of 62 (60%) participants and in the hydromorphone arm by 20 of 64 (31%) participants (difference 28%, 95% confidence interval 12-45, number needed to treat 4, 95% confidence interval 2-9). CONCLUSIONS IV hydromorphone is substantially less effective than IV prochlorperazine for the treatment of acute migraine in the ED and should not be used as first-line therapy. CLINICALTRIALSGOV IDENTIFIER NCT02389829. CLASSIFICATION OF EVIDENCE This study provides Class I evidence that for patients in the ED with migraine, IV prochlorperazine + diphenhydramine is superior to IV hydromorphone.
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Affiliation(s)
- Benjamin W Friedman
- From the Department of Emergency Medicine (B.W.F., E.I., A.L., K.R., P.E.B., E.J.G.), Albert Einstein College of Medicine, and Department of Pharmacy (C.S., E.Z.), Montefiore Health System, Bronx, NY; Permanente Medical Group and the Kaiser Permanente Division of Research (D.R.V.), Oakland; and Kaiser Permanente Sacramento Medical Center (D.R.V.), CA.
| | - Eddie Irizarry
- From the Department of Emergency Medicine (B.W.F., E.I., A.L., K.R., P.E.B., E.J.G.), Albert Einstein College of Medicine, and Department of Pharmacy (C.S., E.Z.), Montefiore Health System, Bronx, NY; Permanente Medical Group and the Kaiser Permanente Division of Research (D.R.V.), Oakland; and Kaiser Permanente Sacramento Medical Center (D.R.V.), CA
| | - Clemencia Solorzano
- From the Department of Emergency Medicine (B.W.F., E.I., A.L., K.R., P.E.B., E.J.G.), Albert Einstein College of Medicine, and Department of Pharmacy (C.S., E.Z.), Montefiore Health System, Bronx, NY; Permanente Medical Group and the Kaiser Permanente Division of Research (D.R.V.), Oakland; and Kaiser Permanente Sacramento Medical Center (D.R.V.), CA
| | - Alexander Latev
- From the Department of Emergency Medicine (B.W.F., E.I., A.L., K.R., P.E.B., E.J.G.), Albert Einstein College of Medicine, and Department of Pharmacy (C.S., E.Z.), Montefiore Health System, Bronx, NY; Permanente Medical Group and the Kaiser Permanente Division of Research (D.R.V.), Oakland; and Kaiser Permanente Sacramento Medical Center (D.R.V.), CA
| | - Karolyn Rosa
- From the Department of Emergency Medicine (B.W.F., E.I., A.L., K.R., P.E.B., E.J.G.), Albert Einstein College of Medicine, and Department of Pharmacy (C.S., E.Z.), Montefiore Health System, Bronx, NY; Permanente Medical Group and the Kaiser Permanente Division of Research (D.R.V.), Oakland; and Kaiser Permanente Sacramento Medical Center (D.R.V.), CA
| | - Eleftheria Zias
- From the Department of Emergency Medicine (B.W.F., E.I., A.L., K.R., P.E.B., E.J.G.), Albert Einstein College of Medicine, and Department of Pharmacy (C.S., E.Z.), Montefiore Health System, Bronx, NY; Permanente Medical Group and the Kaiser Permanente Division of Research (D.R.V.), Oakland; and Kaiser Permanente Sacramento Medical Center (D.R.V.), CA
| | - David R Vinson
- From the Department of Emergency Medicine (B.W.F., E.I., A.L., K.R., P.E.B., E.J.G.), Albert Einstein College of Medicine, and Department of Pharmacy (C.S., E.Z.), Montefiore Health System, Bronx, NY; Permanente Medical Group and the Kaiser Permanente Division of Research (D.R.V.), Oakland; and Kaiser Permanente Sacramento Medical Center (D.R.V.), CA
| | - Polly E Bijur
- From the Department of Emergency Medicine (B.W.F., E.I., A.L., K.R., P.E.B., E.J.G.), Albert Einstein College of Medicine, and Department of Pharmacy (C.S., E.Z.), Montefiore Health System, Bronx, NY; Permanente Medical Group and the Kaiser Permanente Division of Research (D.R.V.), Oakland; and Kaiser Permanente Sacramento Medical Center (D.R.V.), CA
| | - E John Gallagher
- From the Department of Emergency Medicine (B.W.F., E.I., A.L., K.R., P.E.B., E.J.G.), Albert Einstein College of Medicine, and Department of Pharmacy (C.S., E.Z.), Montefiore Health System, Bronx, NY; Permanente Medical Group and the Kaiser Permanente Division of Research (D.R.V.), Oakland; and Kaiser Permanente Sacramento Medical Center (D.R.V.), CA
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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. [PMID: 27300483 DOI: 10.1111/head.12835] [Citation(s) in RCA: 136] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2016] [Accepted: 04/13/2016] [Indexed: 09/01/2024]
Abstract
OBJECTIVE To provide evidence-based treatment recommendations for adults with acute migraine who require treatment with injectable medication in an emergency department (ED). We addressed two clinically relevant questions: (1) Which injectable medications should be considered first-line treatment for adults who present to an ED with acute migraine? (2) Do parenteral corticosteroids prevent recurrence of migraine in adults discharged from an ED? METHODS The American Headache Society convened an expert panel of authors who defined a search strategy and then performed a search of Medline, Embase, the Cochrane database and clinical trial registries from inception through 2015. Identified articles were rated using the American Academy of Neurology's risk of bias tool. For each medication, the expert panel determined likelihood of efficacy. Recommendations were created accounting for efficacy, adverse events, availability of alternate therapies, and principles of medication action. RESULTS/CONCLUSIONS The search identified 68 unique randomized controlled trials utilizing 28 injectable medications. Of these, 19 were rated class 1 (low risk of bias), 21 were rated class 2 (higher risk of bias), and 28 were rated class 3 (highest risk of bias). Metoclopramide, prochlorperazine, and sumatriptan each had multiple class 1 studies supporting acute efficacy, as did dexamethasone for prevention of headache recurrence. All other medications had lower levels of evidence. RECOMMENDATIONS Intravenous metoclopramide and prochlorperazine, and subcutaneous sumatriptan should be offered to eligible adults who present to an ED with acute migraine (Should offer-Level B). Dexamethasone should be offered to these patients to prevent recurrence of headache (Should offer-Level B). Because of lack of evidence demonstrating efficacy and concern about sub-acute or long-term sequelae, injectable morphine and hydromorphone are best avoided as first-line therapy (May avoid-Level C).
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Affiliation(s)
| | | | | | - Mia T Minen
- New York University Langone Medical Center, New York, NY, USA
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Friedman BW, Cisewski DH, Holden L, Bijur PE, Gallagher EJ. Age But Not Sex Is Associated With Efficacy and Adverse Events Following Administration of Intravenous Migraine Medication: An Analysis of a Clinical Trial Database. Headache 2015; 55:1342-55. [DOI: 10.1111/head.12697] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2015] [Revised: 07/13/2015] [Accepted: 07/29/2015] [Indexed: 01/03/2023]
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Friedman BW, Cabral L, Adewunmi V, Solorzano C, Esses D, Bijur PE, Gallagher EJ. Diphenhydramine as Adjuvant Therapy for Acute Migraine: An Emergency Department-Based Randomized Clinical Trial. Ann Emerg Med 2015; 67:32-39.e3. [PMID: 26320523 DOI: 10.1016/j.annemergmed.2015.07.495] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2015] [Revised: 06/09/2015] [Accepted: 07/14/2015] [Indexed: 11/17/2022]
Abstract
STUDY OBJECTIVE More than 1 million patients present to US emergency departments (EDs) annually seeking care for acute migraine. Parenteral antihistamines have long been used in combination with antidopaminergics such as metoclopramide to treat acute migraine in the ED. High-quality data supporting this practice do not exist. We determine whether administration of diphenhydramine 50 mg intravenously+metoclopramide 10 mg intravenously results in greater rates of sustained headache relief than placebo+metoclopramide 10 mg intravenously. METHODS This was a randomized, double-blind, clinical trial comparing 2 active treatments for acute migraine in an ED. Eligible patients were adults younger than 65 years presenting with an acute moderate or severe headache meeting International Classification of Headache Disorders-2 migraine criteria. Patients were stratified according to presence or absence of allergic symptoms. The primary outcome was sustained headache relief, defined as achieving a headache level of mild or none within 2 hours of medication administration and maintaining this level of relief without use of any additional headache medication for 48 hours. Secondary efficacy outcomes included mean improvement on a 0 to 10 verbal scale between baseline and 1 hour, the frequency with which subjects indicated they would want the same medication the next time they present to the ED with migraine, and the ED throughput time. Sample size calculation using a 2-sided α of .05, a β of .20, and a 15% difference between study arms determined the need for 374 patients. An interim analysis was conducted when data were available for 200 subjects. RESULTS Four hundred twenty patients were approached for participation. Two hundred eight eligible patients consented to participate and were randomized. At the planned interim analysis, the data and safety monitoring board recommended that the study be halted for futility. Baseline characteristics were comparable between the groups. Fourteen percent (29/208) of the sample reported allergic symptoms. Of patients randomized to diphenhydramine, 40% (40/100) reported sustained relief at 48 hours, as did 37% (38/103) of patients randomized to placebo (95% confidence interval [CI] for difference of 3%: -10% to 16%). One hour after medication administration, patients randomized to diphenhydramine improved by a mean of 5.1 on the 0 to 10 scale versus 4.8 for those randomized to placebo (95% CI for difference of 0.3: -0.6 to 1.1). Eighty-five percent (84/99) of the patients in the diphenhydramine arm reported they would want the same medication combination during a subsequent ED visit, as did 76% (77/102) of those who received placebo (95% CI for difference of 9%: -2% to 20%). Median ED length of stay was 122 minutes (interquartile range 84 to 180 minutes) in the diphenhydramine group and 139 minutes (interquartile range 90 to 235 minutes) in the placebo arm. Rates of adverse effects, including akathisia, were comparable between the groups. CONCLUSION Intravenous diphenhydramine, when administered as adjuvant therapy with metoclopramide, does not improve migraine outcomes.
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Affiliation(s)
- Benjamin W Friedman
- Department of Emergency Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY.
| | - Lisa Cabral
- Department of Emergency Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY
| | - Victoria Adewunmi
- Department of Emergency Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY
| | - Clemencia Solorzano
- Pharmacy Department, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY
| | - David Esses
- Department of Emergency Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY
| | - Polly E Bijur
- Department of Emergency Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY
| | - E John Gallagher
- Department of Emergency Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY
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Taylor FR, Cooper WM, Kaniecki RG, Ward TN, Roberts JL. Abstracts and Citations. Headache 2015. [DOI: 10.1111/head.12520] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Richer L, Craig W, Rowe B. Randomized controlled trial of treatment expectation and intravenous fluid in pediatric migraine. Headache 2014; 54:1496-505. [PMID: 25168404 DOI: 10.1111/head.12443] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/18/2014] [Indexed: 12/16/2022]
Abstract
OBJECTIVE (1) The primary objectives were (1) to assess the response to intravenous (IV) fluid in children presenting to the ED with migraine and; (2) to assess the effect of treatment expectation on the response to I. BACKGROUND Despite a lack of evidence for the practice, many emergency department (ED) migraine treatment protocols include a bolus of IV fluid. This study assessed the overall response to IV fluid hydration and the effect of expected medication treatment on the pain response among children and adolescents with migraine in an urban ED. METHODS A single-blind, randomized parallel arm trial of 10 mL/kg IV 0.9% sodium chloride for children and adolescents aged 5-17 years presenting to a pediatric ED with migraine. Patients were randomized into group A (no expectation of medication in combination with IV fluid) and group B (expectation that medication may be given simultaneously). All participants were treated with standard care following the 30-minute assessment. RESULTS Forty-seven participants were randomized and 2 were excluded; mean age was 13.3 years and 31 (67.4%) were females. Demographics and baseline characteristics were similar between groups. Overall, there was no statistically significant difference for the primary outcome - change from baseline on the visual analog scale (VAS) at 30 minutes with a mean change of -12.3 mm (standard deviation [SD] 17.9) in group A and -12.7 mm (SD 13.2) in group B (P = .936). The standardized difference between the 2 means (Cohen's d effect size) was low at 0.024 (95% confidence interval [CI] -0.56 to 0.61). Overall, complete headache relief was observed in only 1 participant; 16 of 45 (35.6%; 95% CI 21.8 to 51.2) had a reduction in headache of 33% or more and 8 of 45 (17.8%; 95% CI 6.1 to 29.4%) had a minimum clinical significant difference of 30 mm or more on VAS with 4 in each group. Thirteen of 39 patients with follow-up data (33.3%; 95% CI 19.1 to 50.2%) reported a moderate or severe headache at the 24-hour follow up with no difference between groups; only 3 patients returned to the ED. One participant reported a minor IV-related adverse event. CONCLUSIONS The overall decrease in pain with IV fluid is small and clinically insignificant. Treatment expectation did not significantly influence headache relief at 30 minutes with IV fluid hydration in children or adolescents with migraine in the ED. The average relief of headache with IV fluid alone was small; however, a clinically meaningful response was observed in 17.8%. Recurrence of headache is common in 33% after ED discharge.
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Affiliation(s)
- Lawrence Richer
- Department of Pediatrics, University of Alberta, Edmonton, AB, Canada; Women and Children's Health Research Institute, Edmonton, AB, Canada
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Loder EW, Rizzoli P. Detecting meaningful changes in trials of headache treatments: Which outcome measure is best? Cephalalgia 2012; 32:947-9. [DOI: 10.1177/0333102412455714] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Elizabeth W Loder
- Division of Headache and Pain, Department of Neurology, Brigham and Women’s/Faulkner Hospitals, Boston, USA
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Landy SH, Kaniecki RG, Taylor FR. Abstracts and Citations. Headache 2011. [DOI: 10.1111/j.1526-4610.2011.01950.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Friedman BW, Mulvey L, Esses D, Solorzano C, Paternoster J, Lipton RB, Gallagher EJ. Metoclopramide for acute migraine: a dose-finding randomized clinical trial. Ann Emerg Med 2011; 57:475-82.e1. [PMID: 21227540 DOI: 10.1016/j.annemergmed.2010.11.023] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2010] [Revised: 11/05/2010] [Accepted: 11/11/2010] [Indexed: 12/25/2022]
Abstract
STUDY OBJECTIVE Intravenous metoclopramide is effective as primary therapy for acute migraine, but the optimal dose of this medication is not yet known. The objective of this study is to compare the efficacy and safety of 3 different doses of intravenous metoclopramide for the treatment of acute migraine. METHODS This was a randomized, double-blind, dose-finding study conducted on patients who presented to our emergency department (ED) meeting International Classification of Headache Disorders criteria for migraine without aura. We randomized patients to 10, 20, or 40 mg of intravenous metoclopramide. We coadministered diphenhydramine to all patients to prevent extrapyramidal adverse effects. The primary outcome was improvement in pain on an 11-point numeric rating scale at 1 hour. Secondary outcomes included sustained pain freedom at 48 hours and adverse effects. RESULTS In this study, 356 patients were randomized. Baseline demographics and headache features were comparable among the groups. At 1 hour, those who received 10 mg of intravenous metoclopramide improved by a mean of 4.7 numeric rating scale points (95% confidence interval [CI] 4.2 to 5.2 points); those who received 20 mg improved by 4.9 points (95% CI 4.4 to 5.4 points), and those who received 40 mg improved by 5.3 points (95% CI 4.8 to 5.9 points). Rates of 48-hour sustained pain freedom in the 10-, 20-, and 40-mg groups were 16% (95% CI 10% to 24%), 20% (95% CI 14% to 28%), and 21% (95% CI 15% to 29%), respectively. The most commonly occurring adverse event was drowsiness, which impaired function in 17% (95% CI 13% to 21%) of the overall study population. Akathisia developed in 33 patients. Both drowsiness and akathisia were evenly distributed across the 3 arms of the study. One month later, no patient had developed tardive dyskinesia. CONCLUSION Twenty milligrams or 40 mg of metoclopramide is no better for acute migraine than 10 mg of metoclopramide.
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Affiliation(s)
- Benjamin W Friedman
- Department of Emergency Medicine, Albert Einstein College of Medicine, Bronx, NY 10467, USA.
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