Management of Adults With Acute Migraine in the Emergency Department: The American Headache Society Evidence Assessment of Parenteral Pharmacotherapies

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Abstract

To provide evidence-based treatment recommendations for adults with acute migraine who require treatment with injectable medication in an emergency department (ED). We addressed two clinically relevant questions: (1) Which injectable medications should be considered first-line treatment for adults who present to an ED with acute migraine? (2) Do parenteral corticosteroids prevent recurrence of migraine in adults discharged from an ED?

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Treatment of migraine attacks with sumatriptan. The Subcutaneous Sumatriptan International Study Group.

(1991)

The headache in migraine attacks may be caused by dilatation of certain cranial arteries or arteriovenous anastomoses, by neurogenic dural plasma extravasation, or by both of these mechanisms. Sumatriptan, a novel selective agonist of 5-hydroxytryptamine-like receptors, blocks these phenomena. We investigated its efficacy in migraine. We studied 639 patients with migraine attacks in a randomized, double-blind, placebo-controlled, parallel-group clinical trial. We assessed the effect of subcutaneous injections of 6 or 8 mg of sumatriptan or placebo on the severity of headache and associated migrane symptoms 30, 60, and 120 minutes after treatment. Patients who were not free of pain after 60 minutes subsequently received placebo if they had initially received placebo or 8 mg of sumatriptan, and 6 mg of sumatriptan or placebo if they had initially received 6 mg of sumatriptan. After 60 minutes, the severity of headache was decreased in 72 percent (95 percent confidence interval, 68 to 76 percent) of the 422 patients given 6 mg of sumatriptan, 79 percent (95 percent confidence interval, 71 to 87 percent) of the 109 patients given 8 mg of sumatriptan, and 25 percent (95 percent confidence interval, 17 to 33 percent) of the 105 patients given placebo (data on 3 patients could not be evaluated). As compared with the placebo group, 47 percent (95 percent confidence interval, 38 to 57 percent) more patients who had received 6 mg of sumatriptan and 54 percent (95 percent confidence interval, 43 to 65 percent) more patients who had received 8 mg of sumatriptan had a decrease in the severity of headache (P less than 0.001 for both comparisons). After 120 minutes, 86 to 92 percent of the 511 patients treated with sumatriptan (202 assigned to 6 mg plus placebo, 203 to 6 mg plus 6 mg, and 106 to 8 mg plus placebo) had improvement in the severity of headache, as compared with only 37 percent of the 104 patients who received placebo once or twice (P less than 0.001 for all comparisons). Twenty-one patients were excluded from the analysis because of missing data (19) or protocol violations (2). The response rates did not differ significantly among the sumatriptan regimens. Adverse events were minor and transient in all groups. We conclude that a single 6-mg dose of sumatriptan given subcutaneously is a highly effective, rapid-acting, and well-tolerated treatment for migrane attacks. The administration of a second dose 60 minutes later to patients not responding well to an initial dose affords little additional benefit.

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The minimum clinically important difference in physician-assigned visual analog pain scores.

Brenda K. Todd, Duane J. Funk (1996)

To determine the minimum clinically important difference in physician-assigned visual analog scale (VAS) pain scores. Physicians attending emergency medicine didactic conferences were enrolled in this descriptive study. The subjects sequentially reviewed 11 written scenarios describing patients in moderate to severe pain. The subjects rated their perceptions of each patient's pain on a 100-mm VAS, then contrasted this pain with that of the previous patient scenario. For these contrasts, the subjects chose one of five responses: "much less," "a little less," "about the same," "a little more," or "much more" pain. The minimum clinically important difference was defined as the difference between scores for scenario pairs in which one patient's pain was rated "a little less" or "a little more" severe. There were 230 comparisons by 23 health professionals. Of these, 64 were judged "a little less," and 56 "a little more," painful. These 120 comparisons, with their pain score differences, were used to determine the minimum clinically important difference. Pain judged to be "a little less" or "a little more" severe was associated with a mean difference in VAS scores of 18 mm (95% CI 16-20 mm), corresponding to a decrement of 23% (95% CI 20-26%) from the more painful scenario. Pain research outcomes involving a < 18-mm difference, or a 23% decrement in physician-assigned VAS pain scores, although statistically significant, may have little clinical importance.