At the request of the American Headache Society, Dr. Mia Minen of New York University’s Langone Medical Center and her colleagues set out to develop evidence-based treatment recommendations for adults with acute migraine who require treatment with injectable medications in the emergency department (ED). The investigators aimed to answer the clinically relevant question, “Which injectable medications should be considered first-line treatment for adults who present to an ED with acute migraine?”
The panel performed a search of Medline, Embase, the Cochrane database, and clinical trial registries from inception through 2015. For each medication, the experts determined the likelihood of efficacy. Recommendations were created accounting for efficacy, adverse events, the availability of alternate therapies, and principles of medication action.
The search identified 68 randomized controlled trials using 28 injectable medications. Metoclopramide, prochlorperazine, and sumatriptan each had multiple studies supporting acute efficacy, as did dexamethasone for the prevention of headache recurrence. All other medications had lower levels of evidence.
The panel recommended that clinicians offer intravenous metoclopramide and prochlorperazine, and subcutaneous sumatriptan to eligible adults who present to an ED with acute migraine. Dexamethasone should be offered to these patients to prevent the recurrence of headache. Because of the lack of evidence demonstrating efficacy and a concern about subacute or long-term sequelae, injectable morphine and hydromorphone are best avoided as first-line therapy, the investigators concluded.
The sumatriptan recommendation is especially important because patients can obtain a prescription as they’re leaving the ED, Minen told the Reuters news agency.
“If it works in the ED, patients can try it at home the next time an attack occurs, which will hopefully prevent additional ED visits for migraine,” she said.
Minen stressed that the ED doctor and the patient’s primary care doctor should communicate in case any issues arise as a result of treatment and to determine whether preventive treatment would help.