269 The CHECK Trial: A Comparison of Headache Treatment in the Emergency Department: ProChlorperazine Versus Ketamine

Abstract

In the emergency department (ED), one of the most common chief complaints is headache. Although multiple studies have compared the efficacy of multiple medications in treatment of headaches, many patients still have moderate to severe headaches 24 hours after discharge. Intravenous subdissociative-dose ketamine has been shown to be effective for pain management, but has never been studied for headaches in the ED. For this reason, we designed a study to compare one of the most evidence-supported medications for headache, prochlorperazine, to ketamine in patients with benign headaches in the ED. This study was a multicenter, double-blind, randomized controlled trial on a convenience sample of patients presenting to the ED with a chief complaint of headache. The headaches must have been considered benign without signs or symptoms suggestive of serious intracranial pathology. Patients were randomized to receive either a combination of prochlorperazine and diphenhydramine or ketamine and ondansetron. Baseline data collected included age, sex, race, and initial headache severity. Patients' headache severity was measured on the 100-mm visual analog scale (VAS) at 15, 30, 45, and 60 minutes after treatment. Nausea, vomiting, and anxiety were also assessed at these time intervals. The need for rescue medications and disposition were tracked as well. Patients were contacted at 24-48 hours post-treatment to rate their satisfaction and to see if they were having a headache at that time. There were a total of 54 subjects enrolled from two separate EDs. Three patients withdrew due to side effects of the medications, two in the ketamine group and one in the prochlorperazine group. There was a statistically significant difference in the average decrease in VAS pain score in the prochlorperazine group compared to the ketamine group at t=45 minutes (p=0.026) and t=60 minutes (p=0.049). There was no statistically significant difference between groups in secondary outcomes including vomiting, need for rescue medications, or hospital admission. Follow-up at 24-48 hours was successful for 71% of the prochlorperazine and 78% of the ketamine group. The mean satisfaction score was 8.3/10 for prochlorperazine and 4.9/10 for ketamine (p=0.0008). There was not a statistically significant difference in the percentage of patients who had a headache at the time of follow-up. Prochlorperazine was superior to ketamine in reduction of pain at 45 and 60 minutes after treatment. At 24-48 hour follow-up, patients were also more satisfied with their treatment if they received prochlorperazine.