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Nonopioid treatment superior to opioids for migraine

The nonopioid treatment IV prochlorperazine plus diphenhydramine was significantly more effective at sustained pain relief in patients presenting to the ED with migraine than the commonly used IV hydromorphone, according to findings published in Neurology.

“Migraine patients visit U.S. EDs 1.2 million times annually,” Benjamin W. Friedman, MD, MS, from the Albert Einstein College of Medicine, and colleagues wrote. “Parenteral opioids are used to treat migraine in more than 50% of all ED visits. Hydromorphone, the parenteral opioid used most commonly, is administered in 25% of all migraine visits.”

“Experts caution against the use of opioids for migraine, although scant high-quality data exist,” they added.

Friedman and colleagues conducted a double-blind study to determine how effective IV hydromorphone is at providing sustained headache relief, compared with IV prochlorperazine plus diphenhydramine. Sustained headache relief was defined as achieving a mild headache or no headache within 2 hours of receiving medication and maintaining that level for 48 hours without requiring rescue medication.

The researchers recruited 127 patients from two EDs in New York City with migraine who had not taken an opioid within the past month. Participants were randomly assigned to receive either 1 mg of hydromorphone (n = 64) or 10 mg of prochlorperazine plus 25 mg of diphenhydramine (n = 62). Follow-up calls were conducted 48 hours, 1 month and 3 months after the ED visit.

Data indicated that almost double the number of participants receiving IV prochlorperazine plus diphenhydramine achieved sustained headache relief (60%) after 48 hours than those receiving hydromorphone (31%). More patients in the hydromorphone arm (31%) requested a second dose of medication than those in the prochlorperazine plus diphenhydramine arm (8%). Moreover, 36% of participants receiving hydromorphone asked for other pain-reliever medications, compared with only 6% of those receiving prochlorperazine plus diphenhydramine.

Long-term outcomes, such as number of headache days, return visits to the ED for migraine and functionality in daily life, were similar in both treatment groups.

“Ours is the first randomized study to demonstrate that it is not appropriate to administer the opioid hydromorphone as a first-line therapy for patients with migraine,” Friedman said in a press release. “Given the national trend of opioid dependency and abuse, we hope more clinicians feel encouraged by our findings and will consider more effective nonopioid therapies for migraine management in the ED.”

“While this study demonstrates the overwhelming superiority of prochlorperazine over hydromorphone for initial treatment of acute migraine, the results do not suggest that treatment with IV opioids leads to long-term addiction,” he said in a separate release. “In addition, the results should not be used to avoid the use of opioids for people who have not responded well to anti-dopaminergic drugs.” – by Alaina Tedesco

Disclosure: Friedman and colleagues report no relevant financial disclosures.