Abstract
Objective:To assess the efficacy and tolerability of oral aprepitant, a substance P/neurokinin A receptor antagonist, in controlling nausea associated with IV dihydroergotamine (DHE) administered for medically refractory migrainous headache in patients not responding to standard antiemetics or with a history of uncontrolled nausea with DHE.Methods:This was a retrospective chart review of prospectively collected hourly diary data and clinical notes of patients hospitalized between 2011 and 2015 for inpatient treatment with DHE. Patients were classified using the International Classification of Headache Disorders, 3rd edition (beta version). Peak and average daily nausea scores from hourly diaries, or daily entries of notes, and concurrent antiemetic use were collected and tabulated.Results:Seventy-four patients, of whom 24 had daily diaries, with chronic migraine with or without aura, with or without medication overuse, or new daily persistent headache of a migrainous type, were identified. In 36 of 57 cases in which aprepitant was administered during hospitalization, there was a 50% reduction in the average daily number of as-needed antinausea medications. Of 57 patients, 52 reported that the addition of aprepitant improved nausea. Among 21 of 24 patients with hourly diary data, nausea scores were reduced and in all 12 with vomiting there was cessation of emesis after aprepitant was added. Aprepitant was well tolerated with no treatment emergent adverse events.Conclusions:Aprepitant can be effective in the treatment of refractory DHE-induced nausea and emesis. Given the broader issue of troublesome nausea and vomiting in acute presentations of migraine, general neurologists may consider what place aprepitant has in the management of such patients.Classification of evidence:This study provides Class IV evidence that for patients with medically refractory migraine receiving IV DHE, oral aprepitant reduces nausea.
Highlights
Aprepitant can be effective in the treatment of refractory DHE-induced nausea and emesis
We conducted a retrospective review of patients with migrainous disorders who were admitted to the University of California, San Francisco Headache Center for a 5-day course of IV DHE from June 1, 2011, through April 17, 2015, and received oral aprepitant as antiemetic therapy due to refractory nausea, either at the onset of DHE administration or later during their treatment course
While comparative efficacy studies would be appropriate to ascertain which is the best initial antiemetic path when using DHE, our data support the addition of aprepitant in patients whose conventional antiemetics failed or in those with special cases likely to be refractory to conventional antiemetics
Summary
This was a retrospective chart review of prospectively collected hourly diary data and clinical notes of patients hospitalized between 2011 and 2015 for inpatient treatment with DHE. Peak and average daily nausea scores from hourly diaries, or daily entries of notes, and concurrent antiemetic use were collected and tabulated. We conducted a retrospective review of patients with migrainous disorders who were admitted to the University of California, San Francisco Headache Center for a 5-day course of IV DHE (cumulative dose of 11.25 mg) from June 1, 2011, through April 17, 2015, and received oral aprepitant as antiemetic therapy due to refractory nausea, either at the onset of DHE administration or later during their treatment course. Peak and average daily nausea scores were determined before and after aprepitant administration from patients’ hourly diaries, whereby headache and nausea were rated on an 11-point visual analog graph, or with daily progress notes, or both. Medication administration records were reviewed for other concurrent antiemetic medications given either as standing premedications or as-needed doses for breakthrough nausea
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