“A new comparative study shows that, in patients who visit the emergency department for acute migraine treatment, prochorperazine is more effective than the opioid drug, hydromorphone. The difference was so substantial that the trial was halted early. ” AHS
“Hydromorphone is given in about 25% of all emergency department visits for acute migraine. However, it’s well known that the use of prescription opioids can lead to serious risks of addiction, abuse, and overdose and adversely impact treatment of migraine,” said Peter Goadsby, MD, PhD, FAHS, AHS scientific program committee Chair, professor of neurology at King’s College, London and University of California, San Francisco and Director of NIHR-Wellcome Trust Clinical Research Facility, King’s College Hospital, London. “This study is important in providing clear evidence that hydromorphone is significantly less effective than prochlorperazine in achieving and maintaining headache relief.” AHS
The study was randomized, double-blinded, comparative study. Patients were given prochlorperazine 10 mg plus diphenhydramine 25 mg, or hydromorphone 1 mg. The study looked at reduction of severity AND maintaining that for 48 hours.
The results their was sustained headache relief with significantly more patients with prochlorperazine group (60%) compared to the hydromorphone group (31%).
‘“These new findings support the American Headache Society treatment recommendations for adults presenting to the emergency department with acute migraine,” said Dr. Goadsby. “Physicians should first offer these patients intravenous prochlorperazine, metoclopramide, or subcutaneous sumatriptan, but not morphine or hydromorphone because of a lack of evidence for efficacy and concerns about side effects,” he said.’ AHS
Note: The last time I was in the ER I was given morphine because I cannot take NSAIDs (toradol being the number one treatment around here) due to a severe adverse reaction to them digestive wise. Actually that was because of toradol that reaction started and persists. Hoping one day soon it will spontaneously stop like it started. I am not sure which one but I also cannot take either prochlorperazine or metoclopramide due to Abilify. It is why I am on Zofran for nausea. But I get this study. They are pain-duller not killers and they do not provide sustained relief from a migraine. Not to mention the rebound risks with them if taken regularly. We know there are better options, but like with all things some people those options are not possible for them.
I rarely go to the ER as I tend to reserve that for status migraines, if then. But when I do it can be difficult to find a treatment due to my adverse reactions and medication conflicts. As a result, very difficult to treat said status migraine. Fortunately, lately I have not had a stretch like that. I must say, for that last status migraine the morphine was a blessing given that pain had persisted so long and so acutely. However, if there was something more effective? I’d have them give me that in a Heartbeat. Obviously the idea is to abort it, not temporarily dull in and then have it full force soon after. And I am not entirely sure I have ever been offered anything other than toradol and metoclopramide for a migraine, aside from that last time (morphine and gravol). Certainly never prochlorperazine. So lack of knowledge in the ER is always a factor. I got some mighty fierce looks when I say I cannot take toradol. Unless they want me to hang around a lot longer for other reasons entirely. But it is like they have no conceivable alternative. Trust me when I say, unlike what they certainly speculate, I am not inviting them to offer opiates. Rather something not an NSAID that can treat the migraine. Anything at all. Absolutely anything with the potential to do Something. They are the doctors. I am not. I certainly am not going to presume how to treat a status migraine, when I have a status migraine and my brain is pudding. I just want any sort of relief. I actually never even expect the migraine to actually be aborted. I just want a decrease in intensity so I can tolerate it… which really isn’t a big ask.
There is often an assumption that opiate=pain relief. However, if you have ever taken them for chronic pain you know that simply isn’t the case and often there are indeed better options out there. I think sometimes people think they are getting less relief by being offered something different, but it is just attacking a problem with more precise tools. Of course, every situation is different. We are all different with different medical histories. In general, though, we have to accept opiates are often not the best solution to chronic pain of the migraine sort. We really just want effective treatment that increases our quality of life when it comes to chronic pain management, whatever that may be. When it comes to an ER situation we simply want something that can provide acute sustained relief. Studies, like this, demonstrate that answer isn’t always what we think it might be. And that is fine. As long as it works, that is what matters.