Patients seeking care for migraine in the emergency department experience better pain relief from the intravenous (IV) nonopioid treatment prochlorperazine along with diphenhydramine than they do with the frequently used IV opioid treatment hydromorphone, Montefiore Health System researchers write in Neurology.
Each year migraine patients seek pain relief in U.S. emergency departments (EDs) 1.2 million times, and opioids, including hydromorphone, are used to treat migraine in more than 50% of all ED visits. Montefiore Emergency Medicine physician Benjamin W. Friedman, MD, and colleagues conducted a randomized, double-blind study comparing the use of IV hydromorphone with the nonopioid treatment option of IV prochlorperazine (along with diphenhydramine to prevent the common side effect of restlessness) in 127 patients who visited the ED.
The majority of patients experienced sustained headache relief, reporting a headache level of mild or none within two hours of taking the medication. In addition, they maintained that level for 48 hours without needing any additional medication after the use of the opioid alternative. In fact, almost double the number of patients who received prochlorperazine experienced lasting pain relief compared to the opioid (hydromorphone) recipients.
"Ours is the first randomized study to demonstrate that it is not appropriate to administer the opioid, hydromorphone, as a first line therapy for patients with migraine," said Dr. Friedman. "Given the national trend of opioid dependency and abuse, we hope more clinicians feel encouraged by our findings and will consider more effective nonopioid therapies for migraine management in the ED."
As is typical in double blind clinical trials, researchers did not know which patients received the nonopioid and which received the opioid until after the study was done. They conducted follow-up calls with patients 48 hours, one month, and three months after the ED visit to determine if patients had sustained migraine relief or if they had experienced recurrent headaches after the visit. They also asked about return visits to the ED and the effect of migraine on patients' daily lives. Investigators found that there were similar longer-term outcomes between both groups, including a comparable number of headache days, return visits to the ED, and ability or inability to function in daily life.
"Our study clearly shows there is no benefit to using the opioid hydromorphone as first-line treatment for most migraine patients in the ED," said Dr. Friedman.
Source: Montefiore Medical Center; October 19, 2017.