Page 313 Acute Pain Management

Antiemetics and major tranquillisers
Metoclopramide, as monotherapy or in combination, was effective for the treatment of
headache and nausea, in mild‐to‐moderate migraine, and is considered first‐line therapy in the
emergency department (Colman et al, 2004 Level I). IV prochlorperazine was also more effective
than metoclopramide for initial emergency department treatment of migraine (Coppola et al,
1995 Level II); buccal prochlorperazine was superior to an oral ergotamine‐caffeine
combination or placebo (Sharma et al, 2002 Level II). A combination of indomethacin,
prochlorperazine and caffeine was more effective than sumatriptan (Di Monda et al, 2003
Level II). Parenteral chlorpromazine (Bigal, Bordini & Speciali, 2002 Level II) or low‐dose IM
droperidol were also effective (Richman et al, 2002 Level II); the latter was associated with
a 13% incidence of akathisia.
Other drug treatments
Dexamethasone was similar to placebo in the treatment of migraine, however a single dose
was associated with a 26% reduction in recurrence rate (NNT 9) within 25 hours and offered
a degree of migraine prophylaxis (Colman et al, 2008 Level I; Singh et al, 2008 Level I).
The efficacy of lignocaine in the treatment of migraine is unclear. Analgesia provided by IV
lignocaine was similar to dihydroergotamine, but not as effective as chlorpromazine (Bell et al,
1990 Level II) and in one trial no better than placebo (Reutens et al, 1991 Level II). IN lignocaine
may be effective (Maizels et al, 1996 Level II).
IV magnesium may be useful in the treatment of migraine, however the studies are
contradictory. Magnesium sulphate was effective in a small placebo‐controlled trial (Demirkaya
et al, 2001 Level II), with another trial demonstrating a reduction in all of the symptoms of
migraine with aura (including headache), but only in photo/phonophobia in migraine
without aura (Bigal, Bordini, Tepper et al, 2002 Level II). However, other studies showed that a
combination of magnesium and metoclopramide was less effective than metoclopramide plus
placebo (Corbo et al, 2001 Level II) and there was no significant difference between magnesium,
metoclopramide or placebo (Cete et al, 2005 Level II).
IV sodium valproate was ineffective in treating a migraine attack (Tanen et al, 2003 Level II).
Placebo
A significant placebo effect was observed in migraine trials, particularly if the treatment was
administered by injection (Macedo et al, 2006 Level I) and it may be more common in children
and adolescents (Evers et al, 2009 Level I). CHAPTER 9
Hyperbaric oxygen therapy
Limited evidence demonstrated that hyperbaric oxygen therapy was effective in terminating
migraine attacks within 40 minutes in at least 70% of patients, compared with sham therapy
(NNT 2; 95% CI 1 to 2), but there was no effect on nausea and vomiting, rescue analgesic
requirements or migraine prevention; further research was recommended (Bennett et al,
2008 Level I).
Status migrainosis
Status migrainosis is described as a severe, unremitting, debilitating, migraine, lasting more
than 72 hours, which is not attributable to another disorder and is otherwise typical in quality
to the patient’s usual migraine; it is considered a neurological emergency and usually requires
hospital admission (Headache Classification Subcommittee of the IHS, 2004). ‘Status’ is often
associated with a super‐imposed TTH and multiple unsuccessful trials of migraine treatments,
usually triptans, therefore medication overuse headache must also be considered.

Acute pain management: scientific evidence 265