June 24, 2016
By Marilynn Larkin
NEW YORK - The first-ever guidelines for managing adults with acute migraine in the emergency department (ED) say physicians should avoid injectable opioids and use intravenous metoclopramide or prochlorperazine, or subcutaneous sumatriptan, instead.
"The guidelines were needed because studies have shown that over 25 different medications are used to treat migraine in the ED, some of which don't have good evidence-based (efficacy) data," Dr. Mia Minen of NYU Langone Medical Center in New York City, told Reuters Health by email.
"Moreover, despite their known problems, opioids are administered in up to 60-70% of migraine visits," she said.
To develop evidence-based recommendations on first-line injectable treatments and the use of oral corticosteroids to prevent recurrence after ED discharge, Dr. Minen and an expert panel convened by the American Headache Society searched major databases such as Medline as well as clinical trial registries from inception through 2015.
As reported online June 14 in Headache, they identified 68 randomized controlled trials testing 28 injectable medications and rated each article using the American Academy of Neurology's risk of bias tool.
For each medication, they determined likelihood of efficacy. They then developed the recommendations, accounting for efficacy, adverse events, availability of alternate therapies and principles of medication action.
The authors rated 19 studies as class 1 (low risk of bias); 21 as class 2 (higher risk of bias); and 28 as 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.
The final recommendations included the following: IV metoclopramide and prochlorperazine, and subcutaneous sumatriptan should be offered to eligible adults who present to an ED with acute migraine; dexamethasone should be offered to prevent recurrence of headache; and injectable morphine and hydromorphone are best avoided as first-line therapy because of lack of evidence demonstrating efficacy and concern about sub-acute or long-term sequelae.
Because metroclopramide and prochlorperazine are also used to treat nausea, "ED physicians should be comfortable using them," Dr. Minen observed. "The sumatriptan recommendation is important because patients can get a prescription for it on discharge from the ED. If it works in the ED, patients can then try it at home the next time an attack occurs, which will hopefully prevent additional visits to the ED for migraine."
She noted that patients often leave the ED with ongoing pain, and one study found that in about two-thirds of patients, the headache returns with 24 hours of discharge. Therefore, she advises, "if there are no contraindications, dexamethasone should be offered to prevent recurrence."
Furthermore, Dr. Minen stresses the importance of communication between ED physicians and primary care physicians "to see if the acute medications worked in the ED or there are ongoing issues, so there can be an assessment of whether preventive treatment is indicated."
In an editorial, Dr. Stephen Silberstein of the Jefferson Headache Center in Philadelphia, writes, "What we need is more controlled trials of medications in the borderland of uncertainty and more studies in personalized medicine. With this caveat, I thank the members of the committee for producing a superb guideline and their conclusion 'injectable morphine and hydromorphone are best avoided as first-line therapy.'"
Dr. Lauren Doyle Strauss of Wake Forest University Baptist Medical Center in Winston-Salem, North Carolina, told Reuters Health by email that the release of the guidelines is "very exciting" because until now "the approach to migraine treatment has been varied and not standardized, which can lead to inadequate relief and recurrence of headache after going home, which can be frustrating for patients."
"The hope is that moving forward, future studies will use similar (standards of evidence) so that researchers can continue to improve the way we treat pain for migraineurs in the emergency room," she concluded.
SOURCE: http://bit.ly/2953xqM and http://bit.ly/28WmaPX
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