Which Migraine Treatments Work Best in the ED?

TOPLINE:

For patients with migraine who visit the emergency department (ED), intravenous (IV) chlorpromazine provides superior pain relief at 2 hours and IV metoclopramide combinations are effective in avoiding rescue medications, a Bayesian network meta-analysis suggests.

METHODOLOGY:

• Researchers conducted a systematic review and Bayesian network meta-analysis of 64 randomized controlled trials from MEDLINE, Embase, and Web of Science databases from inception to February 9, 2024.
• The analysis included adult participants presenting to EDs with migraine, and pharmacologic therapies were compared with each other or to a placebo.
• Primary outcomes were adequate pain relief at 2 hours, change in pain intensity at 1 hour, need for rescue drug at 2 hours, and significant adverse reactions.
• Researchers used surface under the cumulative ranking curve (SUCRA) to rank therapeutic agents.

TAKEAWAY:

• Chlorpromazine IV/intramuscular (IM) demonstrated the highest probability of superiority (SUCRA, 87.3%) for adequate pain relief at 2 hours, followed by prochlorperazine IV/IM (80.99%), and propofol (68.54%). Ibuprofen IV was least effective (2.47%).
• The metoclopramide IV-ibuprofen IV combination showed the highest likelihood of superiority for preventing need for rescue drug (SUCRA, 94.6%), followed by metoclopramide IV-dexketoprofen IV (85.53%), and chlorpromazine IV/IM (83.30%). Valproate IV was least effective (7.69%).
• Dexamethasone IV (SUCRA, 79.51%) emerged as most likely superior for avoiding significant adverse reactions, followed by ketorolac IV (79.37%).
• Researchers found significant inconsistencies in the data for pain intensity changes at 1 hour, making the results unreliable and not applicable to broader settings.

IN PRACTICE:

“Chlorpromazine IV/IM is definitely among the most effective, valproate IV is definitely among the least effective, and ketorolac IV/IM is possibly among the least effective as single agents obviating the need for rescue drug,” the authors wrote. “The relative safety of the pharmacologic therapies cannot be determined with sufficient certainty. Further, randomized controlled trials of parenterally administered, and perhaps more relatively effective pharmacologic therapies such as chlorpromazine, prochlorperazine, and metoclopramide-NSAID [non-steroidal anti-inflammatory drug] combinations should more robustly establish which are the best options for migraine in the ED,” they added. 

SOURCE:

The study was led by Ian S. deSouza, MD, SUNY Downstate Health Sciences University and Kings County Hospital Center, New York City. It was published online on December 13, 2024, in Annals of Emergency Medicine.

LIMITATIONS:

The inclusion of an intravenous crystalloid bolus in some studies may have reduced pain intensity in clinically dehydrated participants, potentially inflating the effect estimates for these interventions. Clinical heterogeneity, such as differences in migraine type, participant demographics, and varying inclusion criteria, challenged the transitivity assumption in the network meta-analysis. Potential overrepresentation of the subgroup with moderate to severe pain may have skewed the overall effectiveness estimates, making the findings less generalizable to a broader population with varying pain levels. 

DISCLOSURES:

The authors declared that the study did not receive any specific funding. One author disclosed being on the speakers bureau and serving as a consultant for AstraZeneca.

This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication.