Intravenous Ketorolac vs Intravenous Prochlorperazine for the Treatment of Migraine Headaches

Abstract. Objective : To compare IV ketorolac with IV prochlorperazine as the initial treatment of migraine headaches in the ED. Methods : A prospective, double-blind comparison study was performed, using a convenience sample of 64 patients suffering from migraine headaches presenting to the ED at a tertiary care university teaching hospital. Patients were randomly assigned to receive either 10 mg of prochlorperazine IV or 30 mg of ketorolac IV. Patients scored the severity of their headaches using a 10-cm visual analog pain scale. An initial mark was made on the scale at the time of entry into the study and later another mark was made on a new unmarked pain scale 1 hour after medication administration. Changes in pain scores within each treatment group and between groups were analyzed using the Wilcoxon rank sum test. Results : Prior to treatment, the patients assigned to receive prochlorperazine had a median score of 9.2 cm (mean ± SD pain score of 8.3 cm ±2.1 cm), while the patients receiving ketorolac had a median score of 9.0 (mean pain score of 8.4 cm ± 1.7 cm). There was no significant difference between the pain scores of the participants in the 2 groups prior to treatment (p = 0.80). One hour after medication administration, the patients in the prochlorperazine group had a median score of 0.5 cm (mean 2.1 ± 3.2 cm), while those patients receiving ketorolac had a median pain score of 3.9 (mean 4.0 ± 3.3 cm). The decrease in pain score was significant for both groups of patients (p = 0.0001). The change in pain score for the patients in the prochlorperazine group (median 7.1) was significantly greater than the change in pain score for the patients in the ketorolac group (median 4.0; p = 0.04). Conclusion : Although both drugs were associated with a significant reduction in pain scores, benefit over a placebo agent was not tested. Furthermore, the patients who received prochlorperazine IV for migraine headaches had a statistically significant greater decrease in their pain scores than did those receiving ketorolac IV.     

Pediatric Headaches: What Do the Children Want?

One hundred consecutive children (aged 3 to 17 years), drawn from primary care pediatric clinics, with a greater than 3-month history of headaches completed surveys to determine the type and associated features of their headache and to query their reasons for wanting to see a physician. Additionally, the children were asked to draw pictures of how they felt when they had a headache to assess their nonverbal perceptions. Over 90% of the headaches were migrainous (65% common, 23% classic, 5% basilar). The children wanted three answers from the physician: what was the cause of their headache, what would make it better, and reassurance that they had no life-threatening illness. Furthermore, 33%, of the children's illustrations disclosed depressive features of helplessness, frustration, and anger. Over 20% of the adolescents depicted themselves as dead, dying, or about to be killed by their headache.     

Consistency of Response to Sumatriptan/Naproxen Sodium in a Randomized Placebo‐Controlled,Cross‐Over Study for the Acute Treatment of Migraine in Adolescence

A multi‐centered, randomized, placebo‐controlled, early intervention, cross‐over study was conducted to evaluate the consistency of response of sumatriptan/naproxen sodium 85/500 mg (S/NS) over 4 attacks in the acute treatment of migraine in adolescents. Inclusion of subjects was dependent on their age of 12‐17 years, frequency, and history of migraine headaches (1‐8 per month) over the previous 6 months prior to screening and generally healthy males and females of non‐childbearing potential that were not on excluded medications. Subjects were instructed to treat within 1 hour of pain onset, including when the pain was still mild. Subjects were randomized in a double‐blind fashion using a computer‐generated randomization list in which the study drug was prepared prior to study start, and subjects were allocated to a number in sequential order for each site. Each site was allocated number blocks in sets of 10 depending of the rate of enrollment. The objective of this study was to examine the efficacy of S/NS vs placebo in the primary end‐points of pain‐free response at 2 hours (2hPF), 24‐hour sustained pain‐free response (24hPF), and pain‐free response at 2 hours with early intervention (2hPFE) calculated as percentage out of all attacks. In the study, 94 subjects treated 347 attacks in total: treating 277 with S/NS and 70 with placebo. Compared with placebo, S/NS produced higher 2hPF rates (S/NS 37%, placebo 18%; P < .004), and 2hPFE with rates (S/NS 32%, 18% placebo; P < .03). Compared with placebo, 24hPF rates were S/NS 86%, placebo 78%, P < .17, which were higher than placebo but not clinically significant. 2hPF was reported in at least 2 of the 3 migraines treated with S/NS in 40.4% of subjects. 24hPF was reported in at least 2 of the 3 migraine treated with S/NS in 86.2% subjects. Adverse reactions were generally low and comparable between S/NS and placebo.     

Quantitative Sensory Testing May Predict Response to Sphenopalatine Ganglion Pulsed Radiofrequency Treatment in Cluster Headaches: A Case Series

Pulsed radiofrequency treatment has been described as a nonablative alternative to radiofrequency thermocoagulation for the management of certain chronic pain syndromes. We present our first three patients with long‐standing cluster headaches who were treated with pulsed radiofrequency to the sphenopalatine ganglion. All three patients have had cluster headaches for more than 10 years' duration and experienced minimal relief with conservative treatment. An excellent midterm effect was achieved in two of the three patients and a partial effect in one. No neurological side effects or complications were reported. Quantitative sensory testing consisting of allodynia testing, pressure–pain thresholds, electrical pain thresholds, and conditioned pain modulation (CPM) response testing were used to monitor their sensory processing changes before and after the procedure. From this case series, it might be that cluster headache patients with an impaired CPM response with or without signs of allodynia will respond less favorably to interventional treatment. Further studies are required to validate this hypothesis.     

Remote Electrical Neuromodulation (REN) for the Acute Treatment of Migraine

There is a significant unmet need for novel, effective, and well-tolerated acute migraine treatments. Remote electrical neuromodulation (REN) is a non-pharmacological, non-invasive, acute migraine treatment that stimulates upper arm peripheral nerves to induce conditioned pain modulation – an endogenous analgesic mechanism in which a conditioning stimulation inhibits pain in remote body regions. This review presents the method of action and the clinical data of REN and discusses its potential patient benefits. The clinically meaningful efficacy, together with a very favorable safety profile, suggests that REN may offer a promising alternative for the acute treatment of migraine and could be considered first-line treatment in some patients.