Researchers pinpoint best meds to treat migraine in the ED

New guidelines for doctors will help them treat migraine headaches that are severe enough to bring patients to the emergency department.

According to the guidelines, emergency physicians should avoid injecting migraine patients with morphine or morphine-like drugs, known as opioids. Instead, they should use one of two other intravenous drugs or an injection of sumatriptan.

“These are the first-ever guidelines for managing migraine in the emergency department (ED),” Dr. Mia Minen of NYU Langone Medical Center in New York City, told Reuters Health by email. The guidelines were needed, she said, because over 25 different medications are used to treat migraine in the ED, some of which don’t have good data to support their use.

In addition, she said, “despite their known problems, opioids are administered in up to 60-70 percent of migraine visits.” At the request of the American Headache Society, Minen and colleagues set out to develop evidence-based recommendations.

Searching large databases and clinical trial registries, they found 68 randomized controlled trials testing 28 injectable medications. This kind of trial is considered the gold-standard for medical research. Still, the research team reported in the journal Headache, only 19 of the studies were at low risk of bias. Twenty-eight were at very high risk of bias, which would make their results less reliable.

Based on effectiveness, side effects, and other factors, the research team recommended that one of three drugs be tried first - metoclopramide, prochlorperazine, or sumatriptan – because each had solid data to support its use. The corticosteroid dexamethasone was helpful at keeping the headache from coming back, they found.

All other medications had lower levels of evidence. Injectable morphine and hydromorphone “are best avoided as first-line therapy,” according to the guidelines, because there’s not much evidence that they’re effective and because it can be risky to take them for extended periods.

Minen said the sumatriptan recommendation is especially important because patients can get a prescription as they’re leaving the ED.

“If it works in the ED, patients can try it at home the next time an attack occurs, which will hopefully prevent additional ED visits for migraine,” she said. When appropriate, dexamethasone can also be prescribed to prevent a recurrence, she said.

Minen stressed that the ED doctor and the patient’s primary care doctor should communicate in case any issues arise as a result of treatment and to determine whether preventive treatment would help.

Dr. Lauren Doyle Strauss of Wake Forest University Baptist Medical Center in Winston-Salem, North Carolina, told Reuters Health by email that the release of the guidelines is “very exciting” because until now “the approach to migraine treatment has been varied and not standardized, which can lead to inadequate relief and recurrence of headache after going home, which can be frustrating.”

“If you suffer from migraines,” she advised, “it is important to talk with your doctor about your migraine action plan and which medications are best for you in the emergency room."