Literature Review

Guidelines

Management of Adults With Acute Migraine in the Emergency Department: The American Headache Society Evidence Assessment of Parenteral Pharmacotherapies

1. Should offer (Level B)
2. To relieve the acute headache, intravenous metoclopramide should be offered to adults who present to an ED with acute migraine
3. To relieve the acute headache, intravenous chlorperazine should be offered to adults who present to an ED with acute migraine (Should offer–Level B)
4. To relieve the acute headache, subcutaneous sumatriptan should be offered to adults who present to an ED with acute migraine (Should offer–Leve lB
5. May Offer and May Avoid (Level C)
6. Intravenousacetaminophenmay be offered to adults who present to an ED with acute migraine (May offer–Level C)
7. Parenteral chlorpromazine may be offered to adults who present to an ED with acute migraine(May offer–Level C).
8. Parenteral droperidol may be offered to adults who present to an ED with acute migraine (May offer–Level C)
9. Parenteralhaloperidolmay be offered to adults who present to an ED with acute migraine (Mayoffer–Level C)
10. Intravenousketorolacmay be offered to adults present to an ED with acute migraine (Mayoffer–Level C)
11. Intravenous valproate may be offered to adults who present to an ED with acute migraine (May offer–Level C)
12. No Recommendation (Level U).
13. No recommendation can be made regarding the role of
14. parenteral dexamethasone
15. injectable dihydroergotamine
16. Injectable ketamine
17. intravenous propofol
18. Intravenous magnesium
19. However, intravenous magnesium may be of benefit to patients who present with migraine with aura
20. AVOID.
21. Intravenous diphenhydramine
22. Intravenous hydromorphone
23. Intravenous lidocaine
24. Intravenous morphine
25. Intravenousoctreotide

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Studies

Droperidol vs. Prochlorperazine for Benign Headaches in the Emergency Department

The trial conducted by Miner et al., published in “Academic Emergency Medicine” in 2001, aimed to compare the efficacy of droperidol and prochlorperazine for treating benign headaches in emergency department patients. This prospective randomized clinical trial included 168 patients over an eight-month period in an urban emergency department. Patients were given either droperidol (5 mg intramuscular or 2.5 mg intravenous) or prochlorperazine (10 mg intramuscular or intravenous). Pain perception was measured using a visual analog scale (VAS) at baseline, 30, and 60 minutes post-medication.

Results showed that 60 minutes after medication, the mean decrease in VAS scores was 81.4% for droperidol and 66.9% for prochlorperazine (p = 0.001). At 60 minutes, 90.2% of patients receiving droperidol and 68.6% receiving prochlorperazine had at least a 50% reduction in their VAS scores (p = 0.017). No significant difference between intramuscular and intravenous dosing was detected. Side effects, including dystonia, akathisia, and decreased level of consciousness, were observed in 15.2% of patients receiving droperidol and 9.6% of those receiving prochlorperazine. No significant or persisting morbidity was detected. The study concluded that droperidol was more effective than prochlorperazine in relieving pain associated with benign headaches.

Intravenous chlorpromazine vs intravenous metoclopramide in acute migraine headache. 

The study “Intravenous Chlorpromazine vs Intravenous Metoclopramide in Acute Migraine Headache” by Cameron et al., conducted a prospective randomized double-blind trial to compare the efficacy of intravenous chlorpromazine and metoclopramide in treating acute migraine headaches in the emergency department. The trial included 91 patients across two university-affiliated urban emergency departments. Both drugs were administered in doses of 0.1 mg/kg up to three doses. The study found that both chlorpromazine and metoclopramide were effective in providing pain relief, as measured by a visual analog scale. The average pain relief over 45 minutes was similar for both drugs, and there were no significant differences in blood pressure changes or the number of patients reporting adverse effects. The study concluded that both metoclopramide and chlorpromazine are effective in managing acute migraine headaches and are associated with similar minor side-effect profiles.