Metoclopramide Plus Diphenhydramine Is Preferred Over Ketorolac in the Treatment of Non-Migraine and Non-Cluster Benign Headaches

Loren S. Gavaghan, MD, Jno Disch


AccessMedicine from McGraw-Hill 

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Headaches are a common emergency department (ED) chief complaint, accounting for roughly 4% of all ED visits.[1,2] While secondary causes of headaches must be evaluated and considered, over 95% of headaches are considered primary headaches: migraine, tension-type and cluster. There is a lack of consensus of a preferred or superior treatment, especially in regards to tension-type headaches. First-line therapies remain NSAIDS, acetaminophen and aspirin, but persistent non-migraine, non-cluster headaches that present to the ED do not have a proven single drug therapy or combination drug regimen that is clearly superior.[3] One study illustrated that the vast array of drug therapies used in US Emergency Departments had very little consistency in prescribing patterns.[3] Another systemic review, while not proving a superior treatment regimen, did demonstrate a trend towards the superiority of anti-emetics such as metoclopramide and chlorpromazine over placebo. Another recent study by Weinman found that metoclopramide plus diphenhydramine was superior to IV ketorolac.[1,4] Friedman’s 2013 study was an effort to apply research and develop evidence-based practice for the prescribing practice of tension-type headaches where there currently lacks a consensus. It is also the first to compare the efficacy of a dopamine antagonist (metoclopramide) to an NSAID (ketorolac) in tension-type headaches.[4]