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ACEP Now: Vol 36 – No 05 – May 2017

ILLUSTRATION: Chris Whissen & shutterstock.com

Migraines remain a common presenting complaint in the emergency department. Accounting for 2.1 million visits annually, they can be one of the most frustrating conditions to take care of.^1,2 Nearly 45 percent of migraine sufferers receive the wrong treatment in the emergency department, which may lead to poor patient satisfaction and frequent bounce backs.³ When your department’s “migraine cocktail” doesn’t work and you’ve even tried dipping into some dexamethasone or sumatriptan without much success, you are probably out of options. Most emergency physicians around the country are comfortable with using propofol for rapid-sequence intubation and procedural sedation, but what about for migraines?

A group working in an outpatient headache and pain clinic was the first to accidentally discover the beneficial effects of propofol on intractable headaches.⁴ Krusz et al began noticing a trend after their patients were given a preprocedural dose of propofol for its anxiolytic and antiemetic properties: the patients’ headaches would nearly disappear.⁴ This occurred in six patients prior to receiving a nerve block. The group then began to study this treatment more formally. They enrolled 77 patients who had a refractory headache unresponsive to their typical rescue medication regimen from their outpatient clinic. Propofol was administered in 20–30 mg boluses every three to five minutes intravenously, with an average total dose of 110 mg needed to completely abolish the headache or achieve maximal reduction. There was a pain reduction of 95.4 percent on a 0–10 visual analog scale (VAS) in the 77 patients enrolled, with 82 percent having complete resolution of their headache. Unfortunately, the doses were not reported as mg/kg doses, which makes it difficult to apply to different populations, but they did report that none of their patients fell asleep or lost consciousness during treatment with propofol. This study gave rise to multiple case reports and even some randomized trials.

Nearly 45 percent of migraine sufferers receive the wrong treatment in the emergency department, which may lead to poor patient satisfaction and frequent bounce backs.

Propofol Versus Dexamethasone

The use of dexamethasone in the treatment of migraines has been well researched but with conflicting results. When used in conjunction with other medications, it appears to help, but when used alone, it may not be as efficacious.^5–9 Its benefit in preventing recurrent or relapsing migraines arguably may be its biggest benefit.^10–12 In a prospective, double-blind, randomized, controlled trial (DBRCT), dexamethasone 0.15 mg/kg (max 16 mg) was compared to 10 mg aliquots of propofol every five to 10 minutes (max 80 mg) in 90 adult patients diagnosed with a migraine headache (defined by the International Headache Society).¹³ The two groups were not significantly different in terms of age, sex, symptoms, and VAS pain score prior to treatment. When comparing the rate of response to treatment, propofol was faster and more efficacious than dexamethasone when using the VAS as the marker for resolution.¹³ This study was done in Iran, where they do not have access to intravenous NSAIDs or sumatriptan, and thus lacks generalizability to the United States since the majority of practitioners are not using dexamethasone as a single agent for treating migraines in the emergency department.

Propofol Versus Sumatriptan

In another DBRCT, propofol was compared to sumatriptan as a rescue medication in the emergency department setting.¹⁴ Ninety adult patients between the ages of 18 and 45 with the diagnosis of an acute migraine attack were randomly assigned to either receive 6 mg of subcutaneous sumatriptan or a 30–40 mg bolus of propofol, with intermittent dosing of 10–20 mg to achieve a Ramsay Sedation Scale score of 3 to 4 (ie, responding to commands or a stimulus). The propofol cohort had significantly less pain 30 minutes after administration compared to the sumatriptan group, but the pain reduction evened out after one and two hours. There were no instances of hemodynamic instability or desaturation.

Conclusion

There are some practical limitations that can be expected with the use of propofol for treating migraines. Are you really going to stay in the room for 30–60 minutes to rebolus propofol and monitor the patient, while the waiting room piles up and there is an emergency department full of patients waiting to be seen? While we do have some randomized trials comparing propofol to dexamethasone and sumatriptan, neither of these are the current standard for the initial management of headaches in the emergency department. We need more formal studies comparing propofol to our current “migraine cocktails” that we use in the United States. For now, propofol is probably just another trick up your sleeve that you can use safely in the emergency department if you are willing to devote some time to that patient; otherwise, I don’t know if we’re quite ready to start milking all migraines when they hit the door.

References

1. Barron R, Carlsen J, Duff SB, et al. Estimating the cost of an emergency room visit for migraine headache. J Med Econ. 2003;6:43-53.
2. Edlow JA, Panagos PD, Godwin SA, et al. Clinical policy: critical issues in the evaluation and management of adult patients presenting to the emergency department with acute headache. Ann Emerg Med. 2008;52(4):407-436.
3. Wu J, Hughes MD, Hudson MF, et al. Antimigraine medication use and associated health care costs in employed patients. J Headache Pain. 2012;13(2):121-127.
4. Krusz JC, Scott V, Belanger J. Intravenous propofol: unique effectiveness in treating intractable migraine. Headache. 2000;40(3):224-230.
5. Colman I, Friedman BW, Brown MD, et al. Parenteral dexamethasone for acute severe migraine headache: meta-analysis of randomised controlled trials for preventing recurrence. BMJ. 2008;336(7657):1359-1361.
6. Wasiak J, Anderson JN. Is dexamethasone effective in treating acute migraine headache? Med J Aust. 2002;176(2):83-87.
7. Monzillo PH, Nemoto PH, Costa AR, et al. Acute treatment of migraine in emergency room: comparative study between dexamethasone and haloperidol. Arq Neuropsiquiatr. 2004;62(2B):513-518.
8. Bigal M, Sheftell F, Tepper S, et al. A randomized double-blind study comparing rizatriptan, dexamethsone, and the combination of both in the acute treatment of menstrually related migraine. Headache. 2008;48(9):1289-1293.
9. Friedman MBW, Greenwald P, Bania TC, et al. Randomized trial of IV dexamethasone for acute migraine in the emergency department. Neurology. 2007;69(22):2038-2044.
10. Innes GD, Macphail I, Dillon EC, et al. Dexamethasone prevents relapse after emergency department treatment of acute migraine: a randomized clinical trial. CJEM. 1999;1(1):26-33.
11. Krymchantowski AV, Barbosa JS. Dexamethasone decreases migraine recurrence observed after treatment with a triptan combined with a nonsteroidal anti-inflammatory drug. Arq Neuropsiquiatr. 2001;59(3-B):708-711.
12. Singah A, Alter HJ, Zaia B. Does the addition of dexamethasone to standard therapy for acute migraine headache decrease the incidence of recurrent headache for patients treated in the emergency department? A meta-analysis and systematic review of the literature. Acad Emerg Med. 2008;15(12):1223-1233.
13. Soleimanpour H, Ghafouri R, Taheraghdam A, et al. Effectiveness of intravenous dexamethasone versus propofol for pain relief in the migraine headache: a prospective double blind randomized clinical trial. BMC Neurol. 2012;12:114.
14. Moshtaghion H, Heiranizadeh N, Rahimdel A, et al. The efficacy of propofol vs. subcutaneous sumatriptan for treatment of acute migraine headaches in the emergency department: a double-blinded clinical trial. Pain Pract. 2015;15(8):701-705.