Opioid vs. Prochlorperazine plus Diphenhydramine for Treating Migraine Symptoms

Intravenous hydromorphone is a poor choice for first-line migraine treatment in the emergency department.

Unfortunately, despite extensive evidence specifically demonstrating lack of efficacy, parenteral opioids are commonly used to treat migraine headaches in the emergency department (ED). In a randomized double-blind trial, researchers compared the efficacy of intravenous hydromorphone (1 mg) versus IV prochlorperazine (10 mg) plus diphenhydramine (25 mg) in 127 adults with a diagnosis of migraine and no recent opioid use. Eligible patients presented to two New York City EDs with moderate to severe headache pain.

Patients were offered a second dose of medication 1 hour after the first. Symptoms were assessed on a 4-item headache pain scale (severe, moderate, mild, none) in the ED every hour for up to 4 hours, and by phone call at 48 hours. The primary outcome was sustained headache relief, defined as a reduction in pain to mild or none that was sustained at 48 hours after a single dose of medication.

A second dose was requested by 8% of prochlorperazine and 31% of hydromorphone recipients. The primary outcome was achieved in 60% of patients who received one dose of prochlorperazine, compared with 31% of those who received one dose of hydromorphone. Among patients who received one or two doses of medication, sustained relief was reported by 60% in the prochlorperazine group versus 41% in the hydromorphone group. The study was ended early because “overwhelming superiority” of prochlorperazine for the primary outcome was demonstrated.