Non-narcotic treatment of Migraine in the ER 2023
Migraine is a common problem, affecting 12 % of all people as 25% of women and 6 % of men. It is a very disabling neurological condition and many persons with bad migraine attacks end up in the ER.
In years past many of these Migraine patients were given IV opioid treatment which was not that successful for getting rid of the headache, and was very sedating, and if continued, addictive.
Usually in the ER the patient would have a brief general medical exam including vital signs. Sometimes general labs such as chemistries and blood counts and sometimes a CAT scan of the head would be done.
Most of these patients would be referred to a headache neurologist for an outpatient visit after their ER visit. However, in the days of Covid that might be a new teleneurology visit.
Many of these patients would be given a low dose of an opiate narcotic or a butalbital/analgesic combination drug to clear the ER and get them to their neurology visit.
The problem would be that the opioid narcotic wouldn’t help their presenting headache very much and many patients would return to the ER because of continued pain and disability so that ER doctors are always looking for other drug treatments.
This article is about the successful use of non-narcotic drugs in the ER setting.
Read my Mini Book on Migraine Here.
This is an article by Britt Talley Daniel MD, member of the American Academy of Neurology, the American Headache Society, migraine textbook author, podcaster, YouTube video producer, and blogger.
As a general rule IV prochlorperazine and diphenylhydramine are better than opioid treatment for a severe Migraine attack in the ER. Opioid narcotics should not be used as first-line therapy.
Friedman, BW, et al wrote in Neurology 10/18/2017 on Randomized study of IV prochlorperazine plus diphenhydramine vs IV hydromorphone for migraine.
Objective: To determine outcomes among patients with migraine in the emergency department (ED) who receive IV hydromorphone vs IV prochlorperazine + diphenhydramine.
Methods: This study was conducted in 2 EDs in New York City. Patients who met international criteria for migraine were eligible for participation if they had not used an opioid within the previous month. Clinicians, participants, investigators, and research personnel were blinded to treatment. Patients were randomized in blocks of 4. Participants received hydromorphone 1 mg or prochlorperazine 10 mg + diphenhydramine 25 mg. Diphenhydramine was administered to prevent akathisia, a common side effect of IV prochlorperazine. The primary outcome was sustained headache relief, defined as achieving a headache level of mild or none within 2 hours of medication administration and maintaining that level for 48 hours without the requirement of rescue medication. A planned interim analysis was conducted once 48-hour data were available for 120 patients.
Results: The trial was halted by the data monitoring committee after 127 patients had been enrolled. The primary outcome was achieved in the prochlorperazine arm by 37 of 62 (60%) participants and in the hydromorphone arm by 20 of 64 (31%) participants (difference 28%, 95% confidence interval 12–45, number needed to treat 4, 95% confidence interval 2–9).
Conclusions: IV hydromorphone is substantially less effective than IV prochlorperazine for the treatment of acute migraine in the ER and should not be used as first-line therapy.
Classification of evidence: This study provides Class I evidence that for patients in the ED with migraine, IV prochlorperazine + diphenhydramine is superior to IV hydromorphone.
Editorial Comment
One of many studies showing certain safe, non-narcotic drugs that work better than opioids in the emergency room.
Why does this happen?
Many persons do not recognize they really have Migrane and persist in thinking they just have a Migraine alias (name of a medical condition which is really Migraine). Migraine aliases may be sinus headache, let-down headache, menstrual headache, nocturnal headache, sick headache, one-sided headache, or allergic headache.
None of these conditions alone are recognized by the International Classification of Headache Disorders V3.
Another reason persons present to the ER with bad headaches is that only 20-30% of persons with Migraine have seen a doctor and gotten a diagnosis of Migraine and received a prescription for a useful drug for acute treatment. Currently, 11/29/21, triptans are still the best drugs for acute migraine therapy but they have to be used at headache onset to offer a two hour headache free experience. Many migraineurs do not know this.
Drugs to consider on ER discharge
Butalbital is a barbiturate and has been banned all over the world in every country except the United States and Canada. It is notorious for causing medication overuse headache and not a good oral drug to give patients after an ER visit for headache. It should also be banned in the United States but headache neurologists don’t make laws.
If the ER doctor thinks the patient has Migraine, he might write a small number, like #10 of his favorite triptan advising the patient to treat early and only use 2 treatment days a week until he sees the neurologist.
Also, dihydroergotamine (DHE) given as Migranal nasal spray or Timolol eye drops would be reasonable substitutes.
Hopefully this study will impact emergency room practice to provide better relief for migraine patients who present to the ER.
Read my Big Book on Migraine Here.
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All the best.
Britt Talley Daniel MD