Ketorolac versus meperidine-plus-promethazine treatment of migraine headache: Evaluations by patients

doi:10.1016/0735-6757(95)90081-0

The American Journal of Emergency Medicine

Volume 13, Issue 2, March 1995, Pages 146-150

https://doi.org/10.1016/0735-6757(95)90081-0 Get rights and content

Abstract

This study was designed to compare and contrast the speed and efficacy of meperidine (75 mg)/promethazine (25 mg) intramuscularly to ketorolac (60 mg) intramuscularly, in a double-blind study in reducing the symptoms of migraine headache. Forty-two patients who presented to the emergency department between July 1992 and February 1993, with previous diagnoses of migraine headache, were considered for this study. Patients subjectively evaluated parameters of their migraine headaches (eg, pain and nausea) using a numeric scale and were later asked to reevaluate these same parameters at 30, 60, and 360 minutes after a single intramuscular injection of either ketorolac (60 mg) or meperidine (75 mg)/promethazine (25 mg). Sixty-eight percent of patients given meperidine/promethazine responded whereas 55% of patients given ketorolac responded. The responder group showed a statistically significant reduction in headache within 30 minutes with both drug regimens. There was no statistically significant difference between the number of responders in either group. The responders from both groups had relief that lasted 6 hours after injection. In the nonresponder groups, most of the patients withdrew within 1 hour after treatment. As determined by patient response to treatment of their migraine headaches, there was no statistically significant difference between the ketorolac and the meperidine/promethazine groups.

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Status migrainosus is one of the recognized complications of migraine with or without aura, defined as a persistent debilitating migraine attack lasting for more than 72 h with little reprieve, leading to functional disability. The individual impact of status migrainosus and the substantial healthcare burden are highlighted. Current case series which inform our understanding of this condition are examined with two groups emergent, those with classic status migrainosus and those with episodic status migrainosus. The question as to whether status migrainosus is a distinct biological state beyond the established migraine pathophysiology is examined. With the underlying pathophysiology not fully understood, attention is turned to therapeutic considerations and the available evidence informing practice. A practical approach to treatment of status migrainosus is presented. Given the severity and need for emergency care, options detailed are in line with recommendations for acute migraine care: with a staged approach initially combining subcutaneous sumatriptan with parenteral options including dopamine receptor antagonists, nonsteroidal anti-inflammatories and acetaminophen. The place of combination treatment with parenteral magnesium sulfate, dihydroergotamine, antiepileptics, corticosteroids, and anesthetic agents is outlined. With a paucity of high-quality evidence to consolidate current clinical approaches, consideration of future therapies and research questions is raised.
The THINK (Treatment of Headache with Intranasal Ketamine) Trial: A Randomized Controlled Trial Comparing Intranasal Ketamine with Intravenous Metoclopramide
2019, Journal of Emergency Medicine
Citation Excerpt :
Achieving effective analgesia in these patients can pose a significant challenge. Typical regimens include antiemetic dopamine-antagonists, NSAIDs, and steroids (13–20). Administration of these regimens generally entails intravenous access.
Headache is a common chief complaint in the emergency department (ED) setting.
To compare analgesia with metoclopramide and diphenhydramine vs. intranasal ketamine among ED patients with primary headache.
We enrolled a convenience sample of adults with a primary headache in a randomized, single-blind, placebo-controlled trial. We randomized patients to either a control arm (intravenous metoclopramide and diphenhydramine) or intranasal ketamine. The primary outcome was change in pain 0–100 mm visual analog scale (VAS) score measured at study start and 30 min post completion of initial medication administration. Secondary outcomes included side effects, hospital admission, and return to care within 48–72 h.
All 53 enrolled subjects completed the study, 26 of whom were allocated to the control arm and 27 to intranasal ketamine. The mean change in pain VAS score at 30 min post intervention was 22.2 mm in the control arm vs. 29.0 in the intranasal ketamine arm (effect size difference 6.8 mm, 95% confidence interval −5.8–19.4). The incidence of reported side effects was 65.4% in the control arm vs. 66.7% in the ketamine arm. Three patients (11.5%) allocated to the control arm required admission for headache pain control vs. 1 patient (3.7%) in the intranasal ketamine arm. Three (11.5%) additional patients in the control arm returned to the ED within 48–72 h for headache pain vs. none in the ketamine arm.
In this small randomized study, intranasal ketamine was not superior to standard therapy among ED patients with primary headache syndromes.
Benign Headache Management in the Emergency Department
2018, Journal of Emergency Medicine
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Other studies find that IV prochlorperazine may be as effective as metoclopramide, another antidopaminergic medication (24,26). Promethazine is given in doses of 25 mg intramuscularly (IM) or IV, although IV administration is associated with soft tissue injury with extravasation (5,31–33). There are few studies evaluating its use in the ED, with evaluation as an adjunct for its antiemetic effects.
Headache is a common complaint managed in the emergency department (ED), with emergency physicians focusing on evaluation for life-threatening conditions while treating pain and nausea.
This review evaluates the treatment of benign, primary headaches in the ED, with recommendations provided based on the literature.
Headaches are a major cause of disability in the United States and a common condition managed in the ED. The primary objectives of emergency evaluation of these patients include evaluation for a life-threatening, secondary cause of headache, with treatment of primary headaches. Close evaluation for a secondary cause of headache include consideration of red flags and focused neurologic examination. The diagnosis of primary headaches is clinical. Literature has evaluated medication efficacy in headache treatment, with antidopaminergic medications demonstrating high rates of efficacy when used in combination with nonsteroidal inflammatory drugs or acetaminophen. Dexamethasone can be used for the reduction of headache recurrence. If dehydration is present, intravenous fluids should be provided. Diphenhydramine is not recommended for analgesia but may reduce akathisia associated with prochlorperazine. Ketamine, propofol, and nerve blocks demonstrate promise. Triptan agents are also efficacious, provided absence of contraindications. Most patients are appropriate for discharge with pain improvement.
A variety of medications is available for the treatment of primary headaches in the ED. Antidopaminergic agents demonstrate the highest efficacy and should be provided with acetaminophen and nonsteroidal inflammatory drugs. Dexamethasone may reduce headache recurrence. Other treatments include ketamine, propofol, and nerve blocks.
Diagnosis and Management of the Primary Headache Disorders in the Emergency Department Setting
2009, Emergency Medicine Clinics of North America
Citation Excerpt :
The parenteral nonsteroidal ketorolac has demonstrated efficacy for the acute treatment of migraine. Its overall efficacy is comparable to meperidine,50–52 although less than the antiemetics.53–55 In patients who do not have contraindications to nonsteroidals, such as peptic ulcer disease or chronic kidney disease, this medication dosed at 30 mg intravenously or 60 mg intramuscularly is a reasonable treatment option, either as primary treatment or as adjuvant therapy for acute migraine.
Headache continues to be a frequent cause of emergency department (ED) use, accounting for 2% of all visits. Most of these headaches prove to be benign but painful exacerbations of chronic headache disorders, such as migraine, tension-type, and cluster. The goal of ED management is to provide rapid and quick relief of benign headache, without causing undue side effects, and to recognize headaches with malignant course. Although these headaches have distinct epidemiologies and clinical phenotypes, there is overlapping response to therapy; nonsteroidals, triptans, dihydroergotamine, and the antiemetic dopamine antagonists may play a therapeutic role for each of these acute headaches. This article reviews the diagnostic criteria and management strategies for the primary headache disorders.
The Relative Efficacy of Meperidine for the Treatment of Acute Migraine: A Meta-analysis of Randomized Controlled Trials
2008, Annals of Emergency Medicine
Citation Excerpt :
Our search identified 899 abstracts. We requested 23 articles for full text review and ultimately identified 11 studies involving 12 comparisons that met our entry criteria.12-22 One study included an arm with meperidine and another with butorphanol.11
Despite guidelines recommending against opioids as first-line treatment for acute migraine, meperidine is the agent used most commonly in North American emergency departments. Clinical trials performed to date have been small and have not arrived at consistent conclusions about the efficacy of meperidine. We performed a systematic review and meta-analysis to determine the relative efficacy and adverse effect profile of opioids compared with nonopioid active comparators for the treatment of acute migraine.
We searched multiple sources (Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, CINAHL, and LILACS, emergency and headache medicine conference proceedings) for randomized controlled trials comparing parenteral opioid and nonopioid active comparators for the treatment of acute migraine headache. Our primary outcome was relief of headache. If this was unavailable, we accepted rescue medication use or we transformed visual analog scale change scores by using an established procedure. We grouped studies by comparator: a regimen containing dihydroergotamine, antiemetic alone, or ketorolac. For each study, we calculated an odds ratio (OR) of headache relief and then assessed clinical and statistical heterogeneity for the group of studies. We then pooled the ORs of headache relief with a random-effects model.
From 899 citations, 19 clinical trials were identified, of which 11 were appropriate and had available data. Four trials involving 254 patients compared meperidine to dihydroergotamine, 4 trials involving 248 patients compared meperidine to an antiemetic, and 3 trials involving 123 patients compared meperidine to ketorolac. Meperidine was less effective than dihydroergotamine at providing headache relief (OR=0.30; 95% confidence interval [CI] 0.09 to 0.97) and trended toward less efficacy than the antiemetics (OR=0.46; 95% CI 0.19 to 1.11); however, the efficacy of meperidine was similar to that of ketorolac (OR=1.75; 95% CI 0.84 to 3.61). Compared to dihydroergotamine, meperidine caused more sedation (OR=3.52; 95% CI 0.87 to 14.19) and dizziness (OR=8.67; 95% CI 2.66 to 28.23). Compared to the antiemetics, meperidine caused less akathisia (OR=0.10; 95% CI 0.02 to 0.57). Meperidine and ketorolac use resulted in similar rates of gastrointestinal adverse effects (OR=1.27; 95% CI 0.31 to 5.15) and sedation (OR=1.70; 95% CI 0.23 to 12.72).
Clinicians should consider alternatives to meperidine when treating acute migraine with injectable agents.
Prochlorperazine vs. Promethazine for Headache Treatment in the Emergency Department: A Randomized Controlled Trial
2008, Journal of Emergency Medicine
Headache is a very common medical complaint. Four to six percent of the population will have a debilitating headache in their lifetime; and 1–2% of all Emergency Department (ED) visits involve patients with headaches. Although promethazine is used frequently, it has never been studied as a single-agent treatment in undifferentiated headache. We hypothesized that promethazine would be superior to prochlorperazine in the treatment of headache. We conducted a prospective, double-blinded, randomized, controlled trial on patients presenting to our ED between May and August 2005 with a chief complaint of headache. Each subject was randomized to receive either intravenous promethazine 25 mg or prochlorperazine 10 mg, and graded the intensity of their headache on serial 100-mm visual analog scales (VAS). Patients with dystonic reactions or akathesia were treated with diphenhydramine. Adequate pain relief was defined as an absolute decrease in VAS score of 25 mm. After discharge from the ED, patients were queried regarding the recurrence of headache symptoms, the need for additional pain medications, and the occurrence of any side effects since discharge. Thirty-five patients were enrolled in each group. Both drugs were shown to be effective in treatment of headaches. Prochlorperazine provided a faster rate of pain resolution and less drowsiness when compared to promethazine. Both medications were individually effective as abortive therapy for headache. Prochlorperazine was superior to promethazine in the rate of headache reduction and rate of home drowsiness, with similar rates of akathesia, nausea resolution, patient satisfaction, and headache recurrence within 5 days of discharge.

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Original contributionKetorolac versus meperidine-plus-promethazine treatment of migraine headache: Evaluations by patients☆

Abstract

Pain

Am J Emerg Med

Ann Emerg Med

Ann Emerg Med

Prevalence of migraine headache in the United States

JAMA

Treatment of migraine attacks with Sumatriptan

New Eng J Med

Original contribution
Ketorolac versus meperidine-plus-promethazine treatment of migraine headache: Evaluations by patients☆