Emergency physicians should use any of three drugs as first-line treatments for migraine in the emergency department (ED), according to a new guideline.

A literature review found evidence of efficacy and safety for intravenous metoclopramide, intravenous prochlorperazine, and subcutaneous sumatriptan to treat these patients' headache pain, prompting a Level B recommendation, Mia Minen, MD, of NYU Langone Medical Center in New York City, and colleagues reported online in Headache.

However, opioids -- injectable morphine and hydromorphone -- should be avoided, they said.

"We want to help emergency department physicians realize that there are certain drugs that should be used first-line," Minen told MedPage Today. "In many cases, they probably already have experience using them."

Every year there are 1.2 million ED visits in the U.S. for acute migraine, and most of these patients have a primary care provider and health insurance. But according to Minen's earlier work, many migraine patients go to the ED because they think they have an emergent condition, they can't access care in a timely manner, or because their doctor doesn't have quick access to the needed medications.



Yet there's currently no standard of care for treating acute migraine in the ED, with more than 20 different medications that could be used, Minen said.

To assess the safest and most efficacious treatments, Minen and colleagues on an American Headache Society expert panel reviewed 68 randomized controlled trials involving 28 injectable migraine medications.

Although no medications received a Level-A "must offer" recommendation, the three aforementioned drugs received a Level-B "should offer" recommendation, based on class 1 evidence, the researchers said.

The corticosteroid dexamethasone received the same level recommendation to be given to patients in order to prevent migraine recurrence, they reported.

Other drugs with a Level-C "offer" recommendation included acetaminophen, acetylsalicylic acid, chlorpromazine, dexketoprofen, diclofenac, dipyrone, droperidol, haloperidol, ketorolac, and valproate.

In addition to avoiding the opioids for migraine treatment in the ED, the researchers also advised passing on diphenhydramine, lidocaine, and octreotide.

"We know that opioids are not right for migraine," Minen said. "Studies have shown that 16% to 72% of headache patients are getting opioids, but that's surprising because we've known for 20 to 30 years that opioids are a suboptimal treatment for migraine."

The researchers said they couldn't make a recommendation either way on any of the following because there wasn't enough evidence:
Dexamethasone
Dihydroergotamine
Ergotamine
Ketamine
Lysine clonixinate
Magnesium
Meperidine
Nalbuphine
Propofol
Promethazine
Tramadol
Trimethobenzamide

Stephen Silberstein, MD, of the Jefferson Headache Center in Philadelphia, noted in an accompanying editorial that the "fundamental problem of guidelines that want to comment on old drugs [is that] there are few, if any, studies. The old maxim applies: lack of evidence does not mean lack of efficacy."

"What we need is more controlled trials of medications in the borderland of uncertainty and more studies in personalized medicine," Silberstein wrote.