A meta-analysis of 64 randomized controlled trials reveals the effectiveness of different drugs for treating migraine in the emergency department (ED). The study identifies combination therapies as the most effective in preventing the need for rescue medication.
Researchers conducted a systematic review and Bayesian network meta-analysis of 64 randomized controlled trials from MEDLINE, Embase, and Web of Science databases from inception to February 9, 2024. The analysis included adult participants presenting to EDs with migraine, and pharmacologic therapies were compared with each other or to a placebo.
Primary outcomes were adequate pain relief at 2 hours, change in pain intensity at 1 hour, need for rescue drug at 2 hours, and significant adverse reactions. Researchers found significant inconsistencies in the data for pain intensity changes at 1 hour, making the results unreliable and not applicable to broader settings. The combination of drugs showed the highest likelihood of superiority for preventing the need for rescue drug (SUCRA, 94.6%), followed by metoclopramide IV-dexketoprofen IV (85.53%), and chlorpromazine IV/IM (83.30%). Valproate IV was least effective (7.69%). The authors suggest that chlorpromazine IV/IM is definitely among the most effective, valproate IV is definitely among the least effective, and ketorolac IV/IM is possibly among the least effective as single agents obviating the need for rescue drug. They add that the relative safety of the pharmacologic therapies cannot be determined with sufficient certainty. Further, randomized controlled trials of parenterally administered, and perhaps more relatively effective pharmacologic therapies such as chlorpromazine, prochlorperazine, and metoclopramide-NSAID combinations should more robustly establish which are the best options for migraine in the ED. The study was led by Ian S. deSouza, MD, SUNY Downstate Health Sciences University and Kings County Hospital Center, New York City. It was noted that the inclusion of an intravenous crystalloid bolus in some studies may have reduced pain intensity in clinically dehydrated participants, potentially inflating the effect estimates for these interventions
MIGRAINE EMERGENCY MEDICINE PHARMACOTHERAPY DRUG COMBINATIONS CLINICAL TRIAL
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