New AHS Consensus on Emergency Migraine Management

Pauline Anderson

June 17, 2016

Intravenous (IV) metoclopramide and prochlorperazine, and subcutaneous sumatriptan, should be offered to eligible adults presenting for the first time to an emergency department (ED) with acute migraine requiring treatment with injectable medication, according to new evidence-based recommendations.

An expert panel, convened by the American Headache Society (AHS), also recommends that dexamethasone be offered to these patients to prevent recurrence of headache.

Panel members also suggest that injectable morphine and hydromorphone be avoided as first-line therapies because of the lack of evidence demonstrating efficacy and concern about subacute or long-term sequelae.

The recommendations were published online June 14 in Headache.

An estimated 1.2 million visits to US emergency departments for acute migraine take place every year. There is currently "a lot of variability" in the treatment of these attacks, said author Benjamin W. Friedman, MD, associate professor, emergency medicine, Albert Einstein College of Medicine, Bronx, New York.

"If you look across American emergency departments, there are probably 20 different combinations of parenteral medications used to treat acute migraine, and we know that some are probably suboptimal," he told Medscape Medical News.

Opioids, for example, may have acceptable short-term outcomes but down the road may lead to worsening of the underlying migraine, more return visits to the ED, and issues of abuse and addiction, said Dr Friedman.

"We hope these guidelines will help standardize care that patients receive in the ED and encourage physicians to use the medications that have the most evidence supporting efficacy."

Comprehensive Search

Panel members carried out a comprehensive search of MEDLINE, Embase, the Cochrane database, and clinical trial registries.

They identified 68 randomized controlled trials using 28 injectable medications. Five of 68 trials also provided evidence on the use of corticosteroids for the prevention of migraine recurrence after ED discharge.

Panel members used the the American Academy of Neurology's risk of bias tool. Of the 68 studies, they rated 19 as class I (low risk of bias), 21 as class II (higher risk of bias), and 28 as class III (highest risk of bias).

They addressed two clinically relevant questions:

  • Which injectable medications should be considered first-line treatment for adults who present to an ED with acute migraine? 

  • Do parenteral corticosteroids prevent recurrence of migraine in adults discharged from an ED?

For each medication, the panel determined the likelihood of efficacy. They created recommendations that considered adverse events; availability of alternate therapies; and principles of medication, action, and efficacy.

According to the panel, metoclopramide, prochlorperazine, and sumatriptan each had multiple class I studies supporting acute efficacy. Dexamethasone for preventing headache recurrence also had multiple class 1 studies supporting acute efficacy. All other medications had lower levels of evidence.

IV metoclopramide and chlorperazine and subcutaneous sumatriptan all received the highest recommendation: "Should Offer – Level B." For metoclopramide and prochlorperazine, patients should be warned about possible unpleasant side effects, including akathisia and drowsiness.

Sumatriptan should not be offered to those who have used ergotamine, dihydroergotamine (DHE), or a triptan medication in the previous 24 hours.

Medications that received a "May offer – Level C" recommendation (less evidence) were IV acetaminophen, IV acetylsalicylic acid, parenteral chlorpromazine, IV dexketoprofen, IV diclofenac, IV dipyrone, parenteral droperidol, parenteral haloperidol, IV ketorolac, and IV valproates.

A "May Avoid – Level C" recommendation went to IV formulations of diphenhydramine, hydromorphone, lidocaine, morphine, and octreotide.

No recommendations could be made for several medications, including parenteral dexamethasone; injectable versions of DHE, ergotamine, ketamine, and lysine clonixinate; and IV formulations of magnesium, meperidine, and nalbuphine.

Dr Friedman noted that although guidelines don't come out strongly in favor of DHE, some physicians, including himself, have used it successfully on some patients.

However, he said, "when you're constructing guidelines, you have to rely on the evidence and while the evidence wasn't there to say DHE wasn't any good, there just wasn't a tremendous amount of evidence to say it was good either."

Recurrence Prevention

For the prevention of migraine recurrence, parenteral dexamethasone received a "Should Offer – Level B" recommendation. The ideal dose is not known. Before prescribing this medication, clinicians should consider a patient's risk for treatment-related adverse events, such as loss of glycemic control in diabetic patients.

While the goal is to provide patients with medications that take away their pain quickly and completely without side effects or prevention of headache recurrence, a more likely outcome of ED treatment, according to the authors, is modest reductions in pain.

The recommendations are "most appropriate" for patients who present "de novo" and have not before been treated for migraine in the ED, said Dr Friedman. "So there is no experience to guide us, and so any of these medications are possible."

He stressed that, as with other medications, some patients may respond to particular medication while others won't. "If a patient has a history of responding to a certain medication, then it's most prudent to use that same medication again."

In an accompanying guest editorial, Stephen Silberstein, MD, Jefferson Headache Center, Philadelphia, Pennsylvania, thanked the members of the committee for producing "a superb guideline" and for concluding that "injectable morphine and hydromorphone are best avoided as first-line therapy."

Even though the panel members determined that no recommendation can be made for injectable DHE for adults presenting at an ED with acute migraine, Dr Silberstein pointed out that many clinicians use this medication.

The "fundamental problem" of guidelines that "want to comment on old drugs" is that "there are few, if any, studies," said Dr Silberstein.

"The old maxim applies: lack of evidence does not mean lack of efficacy. But just how important is clinical judgment?"

What is needed, he added, are "more controlled trials of medications in the borderland of uncertainty and more studies in personalized medicine."

The authors have disclosed no relevant financial relationships.

Headache. 2016;56:911-940.  Abstract Editorial

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