Sedative Dosing of Propofol for Treatment of Migraine Headache in the Emergency Department

A Case Series

Jarrod Mosier, MD; Grant Roper, MD; Daniel Hays, PharmD; John Guisto, MD

Disclosures

Western J Emerg Med. 2013;14(6):646-649. 

In This Article

Abstract and Introduction

Abstract

Introduction: Migraine headaches requiring an emergency department visit due to failed outpatient rescue therapy present a significant challenge in terms of length of stay (LOS) and financial costs. Propofol therapy may be effective at pain reduction and reduce that length of stay given its pharmacokinetic properties as a short acting intravenous sedative anesthetic and pharmacodynamics on GABA mediated chloride flux.

Methods: Case series of 4 patients presenting to an urban academic medical center with migraine headache failing outpatient therapy. Each patient was given a sedation dose (1 mg/kg) of propofol under standard procedural sedation precautions.

Results: Each of the 4 patients experienced dramatic reductions or complete resolution of headache severity. LOS for 3 of the 4 patients was 50% less than the average LOS for patients with similar chief complaints to our emergency department. 1 patient required further treatment with standard therapy but had a significant reduction in pain and a shorter LOS. There were no episodes of hypotension, hypoxia, or apnea during the sedations.

Conclusion: In this small case series, sedation dose propofol appears to be effective and safe for the treatment of refractory migraines, and may result in a reduced LOS.

Introduction

Acute migraine headache accounts for approximately 2.1 million emergency department (ED) visits and incurs over $600 million in annual healthcare costs.[1,2] Common ED treatments for migraine headache include various pharmacologic agents, oxygen and/or rehydration.[2] While these treatments are usually ultimately effective, they often have the patient occupying a treatment space for extended periods. This potentially slows patient flow in already burdened ED's. A series of small studies and case reports have shown rapid relief of both chronic headache and acute migraine headache using propofol, a lipid soluble short-acting intravenous anesthetic.[3–9] The majority reported occurred as outpatient procedures or in a monitored pre-anesthesia care unit.[3,4] Only 1 small series was performed in adult ED patients at sub-sedation doses of 10 mg every 5 minutes.[10] Propofol is an ultra short-acting anesthetic that increases GABA mediated chloride flux, exerting an inhibitory effect on synaptic transmission, cerebral blood flow and metabolic rate, and central serotonergic neurons in the raphe nuclei.[11–16] We therefore postulated that propofol could safely be used in an ED setting not only with efficacy but also a substantial reduction in ED length of stay (LOS). Based upon the aforementioned studies, we used sedation dose propofol in a convenience sample of migraine patients presenting to the authors in the ED having failed their usual outpatient treatments. We report a case series of four patients safely and rapidly treated for migraine headache in the ED using sedative dosing of propofol, which we hope will form the basis for a research protocol to evaluate this therapy on a more rigorous basis.

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