Rescue Therapy for Acute Migraine, Part 1

Triptans, Dihydroergotamine, and Magnesium

Nancy E. Kelley, MD, PhD; Deborah E. Tepper, MD

Disclosures

Headache. 2012;52(1):114-128. 

In This Article

Abstract and Introduction

Abstract

Objective.— To review and analyze published reports on the acute treatment of migraine headache with triptans, dihydroergotamine (DHE), and magnesium in emergency department, urgent care, and headache clinic settings.
Methods.— MEDLINE was searched using the terms "migraine" and "emergency," and "therapy" or "treatment." Reports from emergency department and urgent care settings that involved all routes of medication delivery were included. Reports from headache clinic settings were included only if medications were delivered by a parenteral route.
Results.— Acute rescue treatment studies involving the triptans were available for injectable and nasal sumatriptan, as well as rizatriptan. Effectiveness varied widely, even when the pain-free and pain-relief statistics were evaluated separately. As these medications are known to work best early in the migraine, part of this variability may be attributed to the timing of triptan administration.
Multiple studies compared triptans with anti-emetics, dopamine antagonists, and non-steroidal anti-inflammatory drugs. The overall percentage of patients with pain relief after taking sumatriptan was roughly equivalent to that recorded with droperidol and prochlorperazine. Sumatriptan was equivalent to DHE when only paired comparisons were performed.
While the data extracted suggest that magnesium may be effective in treating all symptoms in patients experiencing migraine with aura across all migraine patients, its effectiveness seems to be limited to treating only photophobia and phonophobia.
Conclusions.— Although there are relatively few studies involving health-care provider-administered triptans or DHE for acute rescue, they appear to be equivalent to the dopamine antagonists for migraine pain relief. The relatively rare inclusion of a placebo arm and the frequent use of combination medications in active treatment arms complicate the comparison of single agents with each other.

Introduction

This review is the first installment of a 3-part series evaluating health-care provider—administered rescue therapy for acute migraine in the setting of an emergency department (ED), urgent care center, or headache clinic infusion center. Part 1 summarizes the results from published clinical studies involving triptans, dihydroergotamine (DHE), or magnesium. Pertinent information concerning migraine pathophysiology and the methodology commonly used for the assessment of migraine "rescue therapy" is also included. Part 2 will address the dopamine antagonists, antihistamines, serotonin (5HT)3 antagonists, valproate and others (octreotide, lidocaine, nitrous oxide, propofol, and bupivacaine). Part 3 will address studies involving opioids, non-steroidal anti-inflammatory drugs (NSAIDs), steroids, and postdischarge medications, as well as a general discussion of all therapies presented in the 3 articles.

By the time he or she reaches 18 years of age, nearly every human has some personal experience with headache. About half of the global adult population has an active headache disorder.[1] Approximately 10% of the global adult and pediatric population has migraine, with the highest prevalences in Europe and North America (15% and 13%, respectively) and the lowest in Africa (5%).[1] Based on one recent survey, migraine prevalence in the USA is 12% overall (women 18%, men 6%).[2]

Headache is the fourth most common reason for adults in the USA to seek emergency care. Various studies have indicated that headache accounts for 1.4–3.3 million ED visits annually in the US (1–3% of visits); at least two thirds of these visits involve a primary headache disorder.[3–5]

Patients who come to the ED for treatment of migraine generally have the following characteristics: symptoms unusually severe and/or prolonged; symptoms not typical of their usual headache; and/or usual acute migraine treatment has been ineffective. Over half of migraineurs use over-the-counter "simple" analgesics to treat their headaches, and these are often ineffective.[6] Few ED patients have used migraine-specific medications, such as triptans or ergotamine.[7] Fiesseler et al[8] reported that 14% of patients did not use any medications at all before presenting to the ED. This was significantly more likely to be the case in men than women (31% vs 9%, P = .003) and in those patients not previously seen by a neurologist (22% vs 5%, P = .004).

By the definition provided by the International Classification of Headache Disorders (ICHD-2),[9] migraine is a headache lasting 4–72 hours, with at least two characteristics of unilateral location, pulsating quality, moderate-to-severe intensity, aggravated by routine activity, and accompanied by photophobia and phonophobia or nausea and/or vomiting. The individual must have had at least 5 attacks, and the attacks must not be secondary. If headache has not occurred previously or is atypical, prolonged, and intractable, the individual may present for emergency evaluation and treatment.

General management of migraines in the ED includes sufficient investigation for secondary causes of the acute headache and provision of effective treatment. Once the diagnosis of migraine has been established, the patient should be assessed for volume depletion, especially if there is a recent history of vomiting or reduced oral intake.

Blood pressure should be managed and intravenous (IV) rehydration provided, in addition to a quiet, darkened, restful environment.

Published reports suggest that medical treatment of migraine in the ED can be highly variable.[10,11] For a variety of reasons, parenteral medications are used more often than oral medications to treat acute migraine in ED and headache clinics. Many patients already have tried oral medications at home, sometimes for several days, and these obviously have been ineffective. By the time patients arrive at the ED, they may have severe gastroparesis, nausea, and vomiting, and therefore be less able to retain and absorb oral medications. In addition, ED physicians are motivated to use fast-acting therapies or cost-effective medications that give rapid relief of migraine with consequent discharge from the ED.

Patients want rapid, complete relief of migraine pain and associated symptoms, with complete relief rated more important than rapid relief; also important to patients is that they are able to resume normal activities, that their migraine does not recur, and that any treatment-related side effects are mild and transient.[12,13] Migraine persists or recurs, however, in over 50% of patients after leaving the ED. Discharge plans seldom include measures to prevent recurrence or to re-treat if pain persists.[14]

Parenteral opiates/opioids ("narcotics") and anti-emetics are commonly used as first-line migraine agents in US and Canadian EDs.[15] There is, however, considerable variability in the frequency of narcotic use for migraine across treatment centers, ranging from 16% to 71%.[11] Gupta et al[7] reported that patients in their ED most often (67.5%) received dopamine antagonists, such as metoclopramide, prochlorperazine, and chlorpromazine, followed closely by opioids (64.1%), usually meperidine. About a third of their patients were treated with NSAIDs, and less than 10% received migraine "specific" parenteral medications, such as sumatriptan or DHE. Patients in EDs outside of North America were most likely to be treated with parenteral NSAIDs.[16,17]

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