Study shows superior treatment to hydromorphone for ER treatment of migraine

Hydromorphone—often given as initial treatment for acute migraine in hospital emergency rooms (ERs)—is significantly less effective than a combination of the dopamine agonist prochlorperazine and diphenhydramine, and should no longer be used as first-line treatment, according to study results published in Neurology.

“People go to US emergency departments 1.2 million times a year with migraine, and the opioid drug hydromorphone is used in 25% of these visits, yet there have been no randomized, high-quality studies on its use for acute migraine,” said study author Benjamin W. Friedman, MD, MS, professor, Department of Emergency Medicine, Albert Einstein College of Medicine, Bronx, NY.

Dr. Friedman and colleagues included 127 subjects presenting to two New York ERs with migraine, excluding those who had used an opioid within the previous 30 days. They randomized patients to either intravenously administered hydromorphone (1 mg) or prochlorperazine (10 mg) plus diphenhydramine (25 mg)

The primary outcome of the study was sustained headache relief, which researchers defined as achieving a headache level of mild or none within 2 hours of receiving medication, and maintaining this level for 48 hours without needing rescue medication.

At the 48-hour interim analysis, the trial was halted because 60% of subjects treated with prochlorperazine achieved sustained headache relief, compared with 31% of those treated with hydromorphone (difference: 28%; 95% CI: 12-45; number needed to treat: 4; 95% CI: 2-9).

In addition, 31% of patients treated with hydromorphone requested a second dose, compared with only 8% of those treated with prochlorperazine. Finally, a full 36% of patients treated with hydromorphone requested other rescue pain relievers, compared with only 6% of those treated with prochlorperazine.

Researchers found no between-group differences in the incidence of return to the ER for migraine within 30 days.

Dr. Friedman and colleagues also looked at whether the use of an opioid drug led to addiction or return ER visits for repeated treatment.

“While this study demonstrates the overwhelming superiority of prochlorperazine over hydromorphone for initial treatment of acute migraine, the results do not suggest that treatment with IV opioids leads to long-term addiction,” Dr. Friedman said. “In addition, the results should not be used to avoid the use of opioids for people who have not responded well to antidopaminergic drugs.”