Benjamin W Friedman1, Eddie Irizarry2, Clemencia Solorzano2, Alexander Latev2, Karolyn Rosa2, Eleftheria Zias2, David R Vinson2, Polly E Bijur2, E John Gallagher2. 1. From the Department of Emergency Medicine (B.W.F., E.I., A.L., K.R., P.E.B., E.J.G.), Albert Einstein College of Medicine, and Department of Pharmacy (C.S., E.Z.), Montefiore Health System, Bronx, NY; Permanente Medical Group and the Kaiser Permanente Division of Research (D.R.V.), Oakland; and Kaiser Permanente Sacramento Medical Center (D.R.V.), CA. bwfriedmanmd@gmail.com. 2. From the Department of Emergency Medicine (B.W.F., E.I., A.L., K.R., P.E.B., E.J.G.), Albert Einstein College of Medicine, and Department of Pharmacy (C.S., E.Z.), Montefiore Health System, Bronx, NY; Permanente Medical Group and the Kaiser Permanente Division of Research (D.R.V.), Oakland; and Kaiser Permanente Sacramento Medical Center (D.R.V.), CA.
Abstract
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 ED and should not be used as first-line therapy. CLINICALTRIALSGOV IDENTIFIER: NCT02389829. 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.
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 ED and should not be used as first-line therapy. CLINICALTRIALSGOV IDENTIFIER: NCT02389829. 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.
Authors: Annette M Langer-Gould; Wayne E Anderson; Melissa J Armstrong; Adam B Cohen; Matthew A Eccher; Donald J Iverson; Sonja B Potrebic; Amanda Becker; Rod Larson; Alicia Gedan; Thomas S D Getchius; Gary S Gronseth Journal: Neurology Date: 2013-02-20 Impact factor: 9.910
Authors: Serena L Orr; Benjamin W Friedman; Suzanne Christie; Mia T Minen; Cynthia Bamford; Nancy E Kelley; Deborah Tepper Journal: Headache Date: 2016-06 Impact factor: 5.887
Authors: S C Carleton; R F Shesser; M P Pietrzak; C R Chudnofsky; S Starkman; D L Morris; G Johnson; K J Rhee; C W Barton; J E Chelly; J Rosenberg; M K Van Valen Journal: Ann Emerg Med Date: 1998-08 Impact factor: 5.721
Authors: Benjamin W Friedman; David Esses; Clemencia Solorzano; Niels Dua; Peter Greenwald; Radu Radulescu; Esther Chang; Michael Hochberg; Caron Campbell; Amish Aghera; Tyson Valentin; Joseph Paternoster; Polly Bijur; Richard B Lipton; E John Gallagher Journal: Ann Emerg Med Date: 2007-11-19 Impact factor: 5.721
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