Metoclopramide versus hydromorphone for the emergency department treatment of migraine headaches

Abstract

Study objectives: The recent unavailability of prochlorperazine and droperidol has prompted the use of alternative medications for the emergency department (ED) treatment of migraine headaches. We evaluate the effectiveness of metoclopramide versus hydromorphone for the initial ED treatment of migraine headaches. Methods: We conducted a retrospective cohort study of patients with migraine headache treated at a large urban ED. Information about medications and potential confounders was abstracted from medical records. Pain scores were determined from patient-reported measures (0 to 10) before and after medication interventions. A reduction of 3 or more points after medication was considered effective. Crude and adjusted (using Cox proportional hazards regression) relative risks (RR) were estimated to compare the effects of the medications. Results: A total of 183 subjects were included. Ages ranged from 18 to 79 years (mean 40 years), and 85.8% were women. Patients initially received metoclopramide intravenously (n=89), and hydromorphone intravenously or intramuscularly (n=48: 45 intravenous, 3 intramuscular), or one of several other medications (n=46). There were no significant age, sex, race, or initial pain score differences among these 3 groups. Mean reductions in pain scores after initial medication were 3.9 points for metoclopramide, 2.2 points for hydromorphone, and 2.6 points for all others combined (<i>P</i>=.0009). When metoclopramide versus hydromorphone was compared, the crude RR for effective pain reduction was 1.70 (95% confidence interval [CI] 1.15 to 2.53, <i>P</i>=.003), and the adjusted RR was 1.87 (95% CI 0.95 to 3.69, <i>P</i>=.072). There was no difference in pain reduction between 10-mg and 20-mg doses of metoclopramide (<i>P</i>=.937) or between 0.5-mg, 1-mg, 2-mg, and 4-mg doses of hydromorphone (<i>P</i>=.103). Conclusion: Metoclopramide appears to be more effective than hydromorphone as an initial ED treatment of migraine headaches. Increasing doses of metoclopramide and hydromorphone demonstrated no significant pain reduction.