Sedative dosing of propofol for treatment of migraine headache in the emergency department: a case series

Efficacy of pharmacological therapies for preventing post-dural puncture headaches in obstetric patients: a Bayesian network meta-analysis of randomized controlled trials

BACKGROUND

Post-dural puncture headache (PDPH) is a major complication of neuraxial anesthesia. PDPH usually occurs after Caesarean section in obstetric patients. The efficacy of prophylactic pharmacological therapies remains controversial.

METHODS

Seven pharmacological therapies (aminophylline (AMP), dexamethasone, gabapentin/pregabalin (GBP/PGB), hydrocortisone, magnesium, ondansetron (OND), and propofol (PPF)), were studied in this Bayesian network meta-analysis. The primary outcome was the cumulative incidence of PDPH within 7 days. Secondary outcomes included the incidence of PDPH at 24 and 48 h postoperatively, the severity of headache in PDPH patients (24, 48, and 72 h postoperatively), and postoperative nausea and vomiting (PONV).

RESULTS

Twenty-two randomized controlled trials with 4,921 pregnant women (2,723 parturients received prophylactic pharmacological therapies) were included. The analyses demonstrated that PPF, OND, and AMP were efficient in decreasing the cumulative incidence of PDPH during the follow-up period compared to the placebo group (OR = 0.19, 95% CI: 0.05 to 0.70; OR = 0.37, 95% CI: 0.16 to 0.87; OR = 0.40, 95% CI: 0.18 to 0.84, respectively). PPF and OND had the lower incidence of PONV compared to the placebo group (OR = 0.07, 95% CI: 0.01 to 0.30; and OR = 0.12, 95% CI: 0.02 to 0.63). No significant difference in other outcomes was found among different therapies.

CONCLUSIONS

Based on available data, PPF, OND, and AMP may have better efficacy in decreasing the incidence of PDPH compared to the placebo group. No significant side effects were revealed. Better-designed studies are requested to verify these conclusions.

Inpatient Management of Migraine

Migraine is a frequently disabling neurologic condition which can be complicated by medication overuse headache and comorbid medical disorders, including obesity, anxiety and depression. Although most migraine management takes place in outpatient clinics, inpatient treatment is indicated for migraine refractory to multiple outpatient treatments, with intractable nausea or vomiting, need for detoxification from medication overuse (such as opioids and barbiturates), and significant medical and psychiatric disease. The goals of inpatient treatment include breaking the current cycle of headache pain, reducing the frequency and/or severity of future attacks, monitored detoxification of overused medications, and reducing disability and improving quality of life.

Propofol for Treatment of Acute Migraine in the Emergency Department: A Systematic Review

OBJECTIVES

Propofol has not been extensively studied as an acute migraine therapy; however, based on the limited evidence from outpatient and inpatient settings, propofol has been proposed as an option for patients who present to the emergency department (ED). The purpose of this review was to evaluate the existing literature regarding the safety and efficacy of propofol for acute migraine treatment in the ED.

METHODS

A systematic review of clinical studies of propofol treatment for acute migraine in the ED was performed using Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) guidelines. Trials were identified through PubMed, Google Scholar, clinical trial registries, research registries, and key journals through May 2019. A modified Jadad scoring system was used to assess the methodologic quality of the included randomized controlled trials, and the Newcastle-Ottawa Scale was used for the retrospective cohort study.

RESULTS

Nine studies, including five case reports or series, one retrospective cohort study, and three randomized controlled trials, consisting of 290 patients, were reviewed. All studies in adults reported propofol to be an effective therapy for migraine, but the strength of these results was limited by dosing variations, small sample sizes, and limited generalizability. Pediatric studies produced mixed results.

CONCLUSIONS

Propofol may be an effective rescue therapy for patients presenting to the ED for acute migraine, but its place in therapy based on the limited available evidence is unknown. The safety of propofol for migraine management in the ED has not been adequately examined.

Current Approach to Undifferentiated Headache Management in the Emergency Department

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.

The effect of total intravenous anaesthesia with propofol on postoperative pain after third molar surgery: A double-blind randomized controlled trial

BACKGROUND

Total intravenous anaesthesia (TIVA) with propofol may reduce pain after surgery compared with inhalational anaesthetic techniques. Whether propofol provides analgesic benefit may be influenced by the surgical procedure and anaesthetic/analgesic regime. Third molar surgery is a consistent and fairly standard surgical technique that provides a good model for postoperative pain. We investigated whether propofol TIVA or sevoflurane (SEVO) inhalational anaesthesia would produce better quality pain relief after third molar surgery.

METHODS

In this double-blind, randomized controlled trial, patients scheduled for bilateral third molar surgery received propofol TIVA or SEVO inhalational anaesthesia. Postoperative numerical rating pain scores, analgesic consumption, adverse effects and global pain satisfaction were assessed.

RESULTS

Data from 48 patients in each group were analysed. The area under curves for numerical rating scale pain scores were significantly lower in the propofol TIVA group at rest and during mouth opening between 1 and 72 hr after surgery (p = 0.013 at rest, p = 0.021 with mouth opening). There was no difference in postoperative analgesic consumption. Propofol TIVA was associated with less postoperative headache (p = 0.041 in the postoperative anaesthetic care unit, p = 0.036 in ward). There were no differences in other adverse effects including postoperative nausea and vomiting. Global pain satisfaction and level of postoperative discomfort at 24 hr after surgery were significantly better in the propofol TIVA group (p = 0.008 and p = 0.009, respectively).

CONCLUSION

Propofol TIVA was associated with reduced postoperative pain after bilateral third molar surgery, but did not reduce postoperative analgesic consumption.

SIGNIFICANCE

Choice of general anaesthetic technique can affect postoperative analgesia. The results of this study suggest that propofol TIVA improves postoperative pain and patient satisfaction after third molar surgery compared to inhalational anaesthesia.

The Effect of Propofol on Chronic Headaches in Patients Undergoing Endoscopy

Objective

This study determined acute and long-term effects of propofol administration in patients with severe headaches undergoing endoscopic procedures.

Background

Approximately 13% of the US population is affected by migraines or severe headaches. The effect of propofol on headaches more than a few days after the intervention has not been explored.

Methods

We employed a nonrandomized, prospective observational study that recruited patients with chronic headaches who received propofol from an outpatient endoscopy center for either upper or lower endoscopies. Patients completed the six-item Headache Impact Test (HIT-6) questionnaire prior to the procedure and 30 days after endoscopy. Additionally, the patients' response to propofol two days after endoscopy was assessed via phone.

Results

The age of the participants (n=31) ranged from 20 to 70 years. The mean HIT-6 composite scores were significantly lower (p < 0.05) 30 days after propofol administration when compared to baseline scores. Upon stratification, 23 patients indicated an improved condition, 7 a worsened outcome, and 1 showed no change. Furthermore, mean scores were significantly lower (p < 0.05) in three HIT-6 questions pertaining to the severity of pain, daily activity, and frequency of lying down. Finally, the mean pain score obtained was significantly lower (p < 0.05) two days after procedure.

Conclusions

The results of this suggest that propofol administration should be considered in treating chronic headaches. Double-blind studies are necessary to confirm these results.

Inpatient management of migraine

Migraine is a frequently disabling disorder which may require inpatient treatment. Admission criteria for migraine include intractable migraine, nausea and/or vomiting, severe disability, and dependence on opioids or barbiturates. The inpatient treatment of migraine is based on observational studies and expert opinion rather than placebo-controlled trials. Well-established inpatient treatments for migraine include dihydroergotamine, neuroleptics/antiemetics, lidocaine, intravenous aspirin, and non-pharmacologic treatment such as cognitive-behavioral therapy. Short-acting treatments possibly associated with medication overuse, such as triptans, opioids, or barbiturate-containing compounds, are generally avoided. While the majority of persons with migraine are admitted on an emergency basis for only a few days, outcome studies and infusion protocols during elective admissions at tertiary headache centers suggest a longer length of stay may be needed for persons with intractable migraine.