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.     

Antiemetics in the ED: a randomized controlled trial comparing 3 common agents

We sought to compare the efficacy of 3 intravenous antiemetic medications in ED patients complaining of moderate to severe nausea. This randomized, placebo-controlled, double-blind trial compares 1.25 mg droperidol, 10 mg metoclopramide, 10 mg prochlorperazine, and saline placebo. Adult ED patients complaining of nausea were eligible. Nausea was measured on a 100-mm visual analog scale at 0 and 30 minutes after treatment. A convenience sample of 100 patients was enrolled; 97 had complete data available for analysis. Of these, 22 patients received droperidol, 25 received metoclopramide, 24 received prochlorperazine, and 26 received placebo. Droperidol (-54.5 mm) was significantly better than metoclopramide (-40.2 mm) or prochlorperazine (-40.5 mm) at reducing nausea at 30 minutes (P = .04). There were no significant differences in rescue medication or patient satisfaction; however, droperidol had significantly higher akathisia (71.4% vs 23.5%) at 24-hour follow-up. When administered intravenously to adult patients with moderate to severe nausea, droperidol was more effective than metoclopramide or prochlorperazine but caused more extrapyramidal symptoms. Metoclopramide and prochlorperazine were not more effective than saline placebo. All patients improved over time and possibly with intravenous hydration.     

Intramuscular Droperidol versus Intramuscular Dimenhydrinate for the Treatment of Acute Peripheral Vertigo in the Emergency Department: A Randomized Clinical Trial

OBJECTIVE: The emergency department (ED) treatment of acute peripheral vertigo (APV) has not been well studied. The purpose of this study was to determine the efficacy of intramuscular (IM) droperidol vs IM dimenhydrinate, in the treatment of ED patients with APV. METHODS: The study was a randomized, double-blinded clinical trial, performed at a suburban, teaching ED. A convenience sample of adult patients with symptoms and signs consistent with rigid diagnostic criteria for APV were randomized to one of two treatment groups. Patients more than 65 years of age were excluded to reduce the likelihood of diagnostic misclassification. Demographic and historical features were recorded on a standardized data form. Patients recorded their initial level (t0) of discomfort on a 10-centimeter (cm) visual analog scale (VAS). Treatment group 1 received 2.5 mg droperidol IM, while treatment group 2 received 50 mg dimenhydrinate IM. After 30 minutes (t30), patients again recorded the severity of their symptoms on the VAS. Chi-square, t-tests, and Mann-Whitney were used for statistical comparison as appropriate. All tests were two-tailed, with alpha set at 0.05. Primary outcome parameters were the mean change in VAS score from t0 to t30, and the percentage of patients in each treatment group who felt well enough to go home after t30 without further ED intervention. RESULTS: There were 20 patients in the droperidol group and 20 in the dimenhydrinate group. The two groups were similar with respect to mean age (40 +/- 13 years droperidol vs. 42 +/- 13 years dimenhydrinate; p = 0.6), female sex (60% vs. 50%; p = 0.7), and mean median duration of symptoms [3 (interquartile range 2-12) vs 9 (interquartile range 2-30) hours; p = 0.2]. Mean initial t0 VAS scores were 7.2 +/- 2.3 and 7.8 +/- 1.9 (p = 0.47). Both treatment groups had mean reductions in VAS scores at t30 of 3.3 [95% confidence interval (95% CI) = 2.3 to 4.3]. At t30, 42% of patients in the droperidol group and 45% of patients in the dimenhydrinate group felt well enough to go home without further ED intervention. CONCLUSIONS: The authors found no difference between the therapeutic efficacies of IM droperidol and dimenhydrinate for the treatment of acute peripheral vertigo.     

Management of Acute Undifferentiated Agitation in the Emergency Department: A Randomized Double-Blind Trial of Droperidol, Ziprasidone, and Midazolam

Objectives: To compare the efficacy of sedation, need for rescue sedation, rates of respiratory depression, and complications of droperidol, ziprasidone, and midazolam when used for the treatment of emergency department (ED) patients requiring sedation for acute undifferentiated agitation. Methods: A prospective, randomized, double-blind trial of agitated ED patients requiring emergent sedation was performed. Patients were randomized to receive droperidol 5 mg, ziprasidone 20 mg, or midazolam 5 mg intramuscularly. Interval measurements were made at 0, 15, 30, 45, 60, and 120 minutes and included Altered Mental Status Scale (AMS) scores, oxygen saturations, and end-tidal carbon dioxide levels. Results: A total of 144 patients were enrolled; 50 patients received droperidol, 46 received ziprasidone, and 48 received midazolam. Adequate sedation (mean AMS score <0) was achieved at 15 minutes in patients receiving midazolam (mean AMS score, −0.81) and 30 minutes for patients receiving droperidol (mean AMS score, −1.3) and ziprasidone (mean AMS score, −0.74). Rescue medication for sedation was necessary in 38 of 144 patients (droperidol, 5 of 50; ziprasidone, 9 of 46; midazolam, 24 of 48; p < 0.05). No cardiac dysrhythmias were identified in any treatment group. Respiratory depression that clinically required treatment with supplemental oxygen occurred in 21 of 144 patients (droperidol, 4 of 50; ziprasidone, 7 of 46; midazolam, 10 of 48; p = 0.20). No patients required endotracheal intubation. Conclusions: Acutely agitated ED patients sedated with droperidol or ziprasidone required rescue medications to achieve adequate sedation less frequently than those sedated with midazolam. The onset of adequate sedation is delayed with ziprasidone, relative to the other agents.     

Droperidol vs prochlorperazine for the treatment of acute headache

To determine if droperidol i.v. is as effective as prochlorperazine i.v. in the emergency department (ED) treatment of uncomplicated headache, a randomized, controlled, blinded study was conducted in the Emergency Departments of two urban teaching hospitals. Patients >or= 18 years old with crescendo-onset headache were eligible for inclusion. Ninety-six patients (48 in each group) were randomized to receive droperidol 2.5 mg i.v. or prochlorperazine 10 mg i.v. Baseline characteristics were similar between the two study groups. For the main study outcome, 83.3% in the droperidol group and 72.3% in the prochlorperazine group reported 50% pain reduction at 30 min (p <.01; one-sided test of equivalence). The mean decrease in headache intensity was 79.1% (SD 28.5%) in the droperidol group and 72.1% (SD 28.0%) in the prochlorperazine group (p =.23). It is concluded that droperidol i.v. provided a similar reduction of headache as achieved with prochlorperazine i.v. with a similar incidence of akathisia.     

A randomized clinical trial to assess the efficacy of intramuscular droperidol for the treatment of acute migraine headache.

In a recent case series, we reported that intramuscular droperidol appeared to be an effective therapy for the treatment of acute migraine headache. The objective of the study was to further assess the efficacy of intramuscular droperidol for the treatment of acute migraine headache. The study design was a randomized, clinical trial set in a community-based ED. The population was a convenience sample of ED patients who met International Headache Society acute migraine criteria. Exclusions included pregnancy, use of narcotic or phenothiazine medications within 24 hours. For the protocol, patients were randomized to 1 of 2 treatment groups. Patients and physicians were blinded as to the treatment provided. Patients recorded their initial pain on a 100mm Visual Analog Scale (VAS) Patients were randomized to receive either 2.5 mg droperidol intramuscularly; the other group received 1.5 mg/kg meperidine intramuscularly. After 30 minutes patients recorded their pain on the VAS and recorded their preference for the medication on a Likert Scale. Physicians recorded the incidence of any side effects and the need for rescue medication. Statistical analysis consisted of categorical variables that were analyzed by chi-square, continuous interval data by t-tests and ordinal data by Mann-Whitney U test. The primary outcome parameters were mean VAS score change and the percentage of patients who wanted to go home without rescue medication. The study had an 80% power to detect a 26 mm difference in the mean change in VAS between groups. Of the 29 patients who were enrolled, 15 received droperidol. Both groups were similar with respect to age (30.7 +/- 8.9 years droperdol v 32.7 +/- 9.9 years meperidine; P =.59), female sex (73% v 71%; P =.91), mean headache duration (24.7 +/- 28.3 v 18.3 +/- 25.8 hours; P =.55). The droperidol group had a higher mean initial VAS score (88 v 76 mm; P =.03). The 2 groups were similar with regard to outcome, including: mean change in VAS score (47 v 37 mm; P =.33), average Likert score (1.1 v 1.9; P =.85), and the percentage of patients who did not want rescue medication (67% v 57%; P =.61). The incidence of sedation was 6.7 v 14.3%. Akathisia occurred in 13.3% of pts who received droperidol. We found that intramuscular droperidol was similar in efficacy to meperidine with a low incidence of side effects.     

Patients'' Perceptions of Route of Nonsteroidal Anti-inflammatory Drug Administration and Its Effect on Analgesia

OBJECTIVE: There is a commonly held belief among health care providers that patients respond better to parenteral nonsteroidal anti-inflammatory drugs (NSAIDs) than to oral forms by virtue of the patients' belief that getting an injection means they are receiving "stronger" medicine. To the authors' knowledge, this effect has never been adequately documented in the literature. The objective of this study was to compare the effects of a placebo analgesic injection vs placebo oral analgesia on patients with acute musculoskeletal pain. METHODS: A convenience sample of emergency department (ED) patients with acute musculoskeletal pain secondary to trauma were enrolled. Patients received 225 mL of orange-flavored drink containing 800 mg of ibuprofen. Patients then received either a physiologically inactive starch tablet resembling ibuprofen 800 mg in taste and appearance or a physiologically inactive saline intramuscular (IM) injection resembling ketorolac 60 mg. Both patients and research nurses were blinded to the addition of ibuprofen to the drink and the inactive nature of subsequent medication. Pain was evaluated at time 0 and at 30, 60, 90, and 120 minutes on a 10-mm visual analog scale (VAS). RESULTS: Sixty-four patients completed the study protocol. The VAS scores between groups did not differ significantly at baseline or at each subsequent interval (p = 0.86). CONCLUSIONS: These results contradict the belief that parenteral medications confer a selective placebo effect stemming from patients' beliefs regarding route of administration and efficacy. Therefore, the routine use of IM administration of NSAIDs for suspected enhanced analgesia appears unwarranted.     

Droperidol for acute migraine headache.

The use of intramuscular droperidol to treat acute migraine headache has not been previously reported in the emergency medicine literature. It is a promising therapy for migraine. The authors performed a pilot review of all patients receiving droperidol for migraine in our emergency department (ED) to evaluate its efficacy. We used a retrospective case series, in a suburban ED with an annual patient census of 48,000. All patients with a discharge diagnosis of migraine headache who were treated with i.m. droperidol during a consecutive 5-month period in our ED were identified. All patients received droperidol 2.5 mg intramuscular. As per ED protocol, their clinical progress was closely followed and documented at 30 minutes after drug administration (t30). Demographic and clinical variables were recorded on a standardized, closed-question, data collection instrument. The primary outcome measurement was relief of symptoms at t30 to the point that the patient felt well enough to go home without further ED intervention (symptomatic relief). Thirty-seven patients were treated (84% female), with an ED diagnosis of acute migraine with droperidol during the study period. The mean age was 36 +/- 12 years. Analgesics had been used within 24 hours before ED presentation by 62% of patients. At t30, 30 (81%) patients had symptomatic relief, 2 (5%) felt partial relief but required rescue medication, and 5 (14%) had no relief of symptoms. Drowsiness (14%) and mild akathisia (8%) were the only adverse reactions observed following drug administration. Droperidol 2.5 mg intramuscular may be a safe and effective therapy for the ED management of acute migraine headache. Randomized, controlled trials are warranted to further validate the findings of this preliminary study.     

Intramuscular Ketorolac vs Oral Ibuprofen in Emergency Department Patients with Acute Pain

Objective: To determine whether IM ketorolac is superior to oral ibuprofen in patients presenting to an ED in moderate to severe pain.
Methods: This prospective, randomized, double-blind study involved a convenience sample of 119 patients aged a 18 years who presented to an urban teaching hospital ED with a self-assessed pain intensity score of 5, 6, 7, or 8 (on a numerical rating scale of 0–10). Patients were randomized to receive either 60 mg of IM ketorolac and a placebo capsule or 800 mg of oral ibuprofen and a saline injection. Pain scores were measured at 0, 15, 30, 45, 60, 90, and 120 minutes after dosing. Supplemental analgesics were allowed in accordance with standard medical practice.
Results: There were 18 patients excluded who did not remain in the ED for the full 2-hour study period. Of those completing the trial, 53 patients received ketorolac and 48 patients received ibuprofen. There were no significant differences in pain scores between ketorolac and ibuprofen at any time during the study. However, there was a statistically significant decrease in pain over time in both treatment groups. Yet, 40% of the patients continued to report pain intensity scores of 5–8 at 2 hours after treatment.
Conclusions: IM ketorolac and oral ibuprofen provide comparable levels of analgesia in ED patients presenting with moderate to severe pain. Unfortunately, 40% of all the patients had inadequate pain relief (pain score ≥5) from either ketorolac or ibuprofen.     

Comparison of Hydromorphone and Meperidine for Ureteral Colic

Objective: To compare the efficacies of meperidine and hydromorphone in the treatment for ureteral colic in the emergency department (ED).
Methods: A prospective, double-blind, randomized clinical trial was conducted over six months at a tertiary referral center with 93,000 annual ED visits. Seventy-three patients completed the study. The patients received either 1 mg of hydromorphone or 50 mg of meperidine IV at t = 0. Pain intensity was determined using a 10-cm visual analog scale at t = 0, 15, 30, 60, and 120 minutes. A second dose of the study drug could be given between t = 15 and t = 120 minutes when the clinician believed the initial dose was ineffective. Patients requiring more than one additional dose of analgesia were treated as nonresponders and were removed from the study.
Results: Thirty-six patients received hydromorphone and 37 received meperidine. The initial pain intensities (hydromorphone group = 8.4 ± 1.5; meperidine group = 8.5 ± 2.1), age distributions, sex distributions, and side effects of the two groups were comparable. Pain relief was better (p < 0.05) with hydromorphone at t = 15, 30, 60, and 120 minutes. The hydromorphone group required rescue analgesia less often (31% vs 68%, p < 0.01), had fewer IV pyelographies (IVPs) (28% vs 54%, p < 0.05), and had a lower proportion of hospital admissions (25% vs 49%, p = 0.08).
Conclusions: For the fixed doses used in this study, the adult ureteral colic patients receiving hydromorphone achieved more pain relief, required less rescue medication, underwent fewer IVPs, and avoided hospital admission more frequently than did those receiving meperidine.     

A Randomized, Clinical Trial Comparing Oral Celecoxib 200 mg, Celecoxib 400 mg, and Ibuprofen 600 mg for Acute Pain

OBJECTIVE: Celecoxib is a selective cyclooxygenase-2 (COX-2) inhibitor used to treat pain. The objective of this study was to compare the efficacies of celecoxib and ibuprofen for the treatment of acute pain. The null hypothesis was that no difference between celecoxib and ibuprofen exists. METHODS: The study was a prospective, randomized, double-blind, controlled clinical trial. After consent, patients rated their pain on a 100-mm visual analog scale (VAS) and categorical intensity pain scale. Patients were then randomized to receive 200-mg or 400-mg celecoxib or 600-mg ibuprofen (all orally). Patients were contacted 5 hours after receiving study medication when a second VAS score was recorded, along with categorical pain intensity, pain relief score, side effects, and number of rescue medications taken. The main outcome measures were change in visual analog pain and categorical pain intensity scores, and pain relief scores, at five hours. RESULTS: One hundred ten patients were evaluated and 105 were enrolled. Thirty-four received celecoxib 200 mg, 32 received celecoxib 400 mg, and 39 received ibuprofen 600 mg. Ninety-one were available for the five-hour VAS and 88 for the five-hour categorical pain intensity and pain relief analysis: The two patients who were unable to read a VAS were excluded, and two enrolled patients withdrew prior to medication. One patient was excluded because his injury was a fracture, and therefore did not meet the inclusion criteria. There was no statistical difference among the treatment groups in age, time from injury to medication, initial VAS score, percent lost to follow-up, or treatment with adjunctive therapy. There was no statistical difference in change of VAS among the groups at five hours: ibuprofen 600 mg (-23.8 mm [95% CI = -31.56 mm to -16.1 mm] [n = 32]), celecoxib 200 mg (-16.1 mm [95% CI = -24.3 mm to -7.98 mm] [n = 31]), and celecoxib 400 mg (-12.4 mm [95% CI = -23.1 mm to -1.8 mm] [n = 30]) (p = 0.16). There was no significant difference between the groups, at five hours, in change of categorical pain intensity (p = 0.11) or pain relief scores (p = 0.059), though the pain relief scale approached significance favoring ibuprofen. CONCLUSIONS: No significant difference exists among emergency department (ED) patients treated for acute pain, at five hours, with celecoxib 200 mg, celecoxib 400 mg, or ibuprofen 600 mg, though the power of the study to detect a change was low, 36%. However, the magnitude of pain relief for celecoxib, coupled with the cost of the medication, questions its use in the immediate ED setting.     

Pediatric Procedural Sedation with Ketamine: Time to Discharge after Intramuscular versus Intravenous Administration

Objectives: Ketamine is an attractive agent for pediatric procedural sedation. There are limited data on time to discharge comparing intramuscular (IM) vs. intravenous (IV) ketamine. The authors set out to determine whether IM or IV ketamine leads to quicker discharge from the emergency department (ED) and how side effect profiles compare. Methods: All patients who had received ketamine IM or IV at a tertiary children’s hospital ED during the 3‐year study period (2004–2007) were identified. Prospective sedation registry data, retrospective medical records, and administrative data were reviewed for drug dosages, use of additional agents, time of drug administration to discharge, total ED time (triage to discharge), and adverse events. A subgroup analysis for patients requiring five or fewer sutures (short suture group) was performed. Results: A total of 229 patients were enrolled (60% male) with median age of 2.8 years (IQR =1.8–4.3 years) and median weight of 15.7 kg (range = 8.7–74 kg). Ketamine was most frequently employed for laceration repair (80%) and foreign body removal (9%). Overall, 48% received ketamine IM and 52% received it IV. In the short‐suture subgroup, 52% received ketamine IM, while 48% received it IV. Multivariate linear regression analysis determined time from drug administration to patient discharge as 21 minutes shorter for IV compared with IM administration, adjusted for age and number of additional doses (R² = ?0.35; 95% CI = ?0.5 to ?0.19; p < 0.001). Total time in the ED (triage to discharge) comparing IV versus IM administration, adjusting for age and gender and number of additional doses, was not significantly different (p = 0.16). In the short‐suture subgroup, time to discharge from administration was also shorter in the IV ketamine group (R² = ?0.454; 95%CI = ?0.66 to ?0.25; p < 0.001) but similar for total time in ED (p = 0.16). Overall, adverse events occurred in 35% (95% CI = 27% to 45%) of the IM group and 20% (95% CI = 13% to 28%) of the IV group (p = 0.01). Only one patient required brief bag‐mask ventilation. Conclusions: In this institution, time from drug injection to discharge was shorter in the IV compared to IM ketamine group, both overall and for the short‐suture group. However, time from triage to discharge was similar.     

Prochlorperazine vs. promethazine for headache treatment in the emergency department: a randomized controlled trial

Headache is a very common medical complaint. Four to six percent of the population will have a debilitating headache in their lifetime; and 1-2% of all Emergency Department (ED) visits involve patients with headaches. Although promethazine is used frequently, it has never been studied as a single-agent treatment in undifferentiated headache. We hypothesized that promethazine would be superior to prochlorperazine in the treatment of headache. We conducted a prospective, double-blinded, randomized, controlled trial on patients presenting to our ED between May and August 2005 with a chief complaint of headache. Each subject was randomized to receive either intravenous promethazine 25 mg or prochlorperazine 10 mg, and graded the intensity of their headache on serial 100-mm visual analog scales (VAS). Patients with dystonic reactions or akathesia were treated with diphenhydramine. Adequate pain relief was defined as an absolute decrease in VAS score of 25 mm. After discharge from the ED, patients were queried regarding the recurrence of headache symptoms, the need for additional pain medications, and the occurrence of any side effects since discharge. Thirty-five patients were enrolled in each group. Both drugs were shown to be effective in treatment of headaches. Prochlorperazine provided a faster rate of pain resolution and less drowsiness when compared to promethazine. Both medications were individually effective as abortive therapy for headache. Prochlorperazine was superior to promethazine in the rate of headache reduction and rate of home drowsiness, with similar rates of akathesia, nausea resolution, patient satisfaction, and headache recurrence within 5 days of discharge.     

Droperidol versus ondansetron for nausea treatment within the emergency department

Objective

A randomised single-blind trial was undertaken in an adult ED population, comparing the effectiveness of droperidol 2.5 mg IV with ondansetron 8 mg IV for the treatment of nausea and vomiting.

Methods

Patients were randomly allocated to receive droperidol (n = 60) or ondansetron (n = 60). Patients rated their nausea severity on a Visual Analogue Scale (VAS) immediately before and 30 min after drug administration. The primary outcome was of symptom improvement, defined by a VAS change ≥−8 mm 30 min post-treatment. Mean VAS change and percentage experiencing desired effect were secondary outcomes compared.

Results

Of 120 study patients, 60 (50%) received droperidol or ondansetron. Symptom improvement occurred in 93% (56 of 60) and 87% (52 of 60), respectively (P = 0.362). Mean VAS change was −38 mm and −29 mm, respectively (P = 0.031). Percentage of patients indicating desired effect was 85% and 63%, respectively (P = 0.006). Additional antiemetics were required for 16% and 37% of subjects, respectively (P = 0.006).

Conclusion

There was no statistically significant difference in the primary outcome of symptom improvement between droperidol and ondansetron. Secondary outcomes which favour droperidol warrant further exploration.     

Current Emergency Treatment of Severe Migraine Headaches

SYNOPSIS
Objective: To compare the efficacy of the combination of meperidine and hydroxyzine IM, versus dihydroergotamine and metoclopramide IV in the treatment of severe migraine headaches.
Design: This was a randomized double-blind, double-dummy study.
Setting: Established patients, whose headache had failed to respond to their usual abortive agent, were invited to an out-patient headache clinic for the study.
Patients: Twenty-eight patients, diagnosed as suffering from either migraine headache or chronic daily headache, were screened on arrival to exclude life-threatening causes.
Intervention: Group A (14 patients) received dihydroergotamine 1mg and metoclopramide 10mg IV and a placebo injection IM, and Group B (14 patients) received meperidine 75mg and hydroxyzine 75mg IM and a placebo injection IV.
Main Outcome Measures: Patients rated their headaches on a scale of 0-3 prior to treatment and again at 30 and 60 minutes.
Results: Both groups experienced improvement in headache severity. (Group A P=0.001 and Group B P=0.003). Improvement in pain scale score was greater for Group A than Group B, (P=0.006). The number of patients having s mild or no headache in Group A (13/14) was significantly greater than Group B (3/14). (P<0.001)
Conclusions: The combination of dihydroergotamine and metoclopramide IV should replace the standard IM narcotic and antiemetic as the parenteral treatment of choice for severe migraine headache.     

T HE I NCIDENCE AND T REATMENT OF P REHOSPITAL M OTION S ICKNESS

Objectives. The authors' objectives were: 1) to determine the incidence of motion sickness during ambulance transport on a mountainous route in healthy volunteers, and 2) to determine if droperidol alleviated the signs and symptoms of motion sickness in those volunteers who developed it. Methods. This was a prospective, randomized, double-blind, placebo-controlled trial. Subjects were healthy volunteers over age 18 and not currently taking an antiemetic. Participants were transported in the back of an ambulance over a mountainous road. Those who developed motion sickness rated their nausea on a 100-mm visual analog scale (VAS) and were randomized to receive placebo (saline) or 2.5?mg droperidol intravenously. Symptoms were recorded on a VAS every 5 minutes until the end of the transport. Incidence of motion sickness was calculated as a percentage with 95% confidence intervals (CIs). Pretreatment characteristics were compared with chi-square tests, and mean VAS scores were compared using t-tests. Results. Thirty-seven subjects completed the study. Sixteen (43%, 95% CI = 27%?59%) developed motion sickness. Fifteen were randomized and completed data collection. Eight received droperidol (mean baseline VAS, 45) and seven received placebo (mean baseline VAS, 40). Droperidol trended toward a greater mean reduction of nausea than placebo at 5 minutes (20 versus 4, p = 0.077). Conclusions. The incidence of motion sickness during ambulance transport in a mountainous setting is substantial. There was a strong trend toward a positive treatment effect with droperidol. Further prospective study in an actual patient setting is warranted.     

Intravenous Chlorpromazine vs Intravenous Metoclopramide in Acute Migraine Headache

Objective: To compare the efficacy of IV chlorpromazine with that of IV metoclopramide in the treatment for acute migraine headache in the ED.
Methods: A prospective randomized double-blind trial was undertaken at two university-affiliated urban EDs with a combined annual census of more than 85,000 patients. Included in the study were patients presenting to the ED with a diagnosis of migraine headache. The subjects were randomized to receive 0.1 mg/kg/dose IV of either chlorpromazine (CPZ) or metoclopramide (MC), up to a total of three doses.
Results: Ninety-one patients completed the protocol; 44 received MC and 47 received CPZ. The demographics of the two groups were similar. Both drugs provided, for the majority of patients, adequate pain relief as measured on a visual analog scale (VAS) completed every 15 minutes from T = 0 minutes to T = 45 minutes. The average pain relief over 45 minutes (ΔVAS) for CPZ was 4.87 cm, vs 4.34 cm for MC (p = 0.35). There also was no statistically significant difference in blood pressure (BP) changes (ΔBP < 2 mm Hg for both systolic and diastolic BPs, p = 0.47 and 0.33) or numbers of patients reporting adverse effects (AEs) (CPZ: 16 of 35; MC: 13 of 29, p = 0.43). There was no severe AE with either study drug.
Conclusions: Metoclopramide and chlorpromazine administered IV are both effective in the management of acute migraine headache. They are associated with similar minor side-effect profiles.