Comparing the Therapeutic Effects of Dexamethasone-Metoclopramide with Ketorolac in Relieving Headache in Patients with Acute Migraine Attacks Presenting to the Emergency Department
Introduction: Migraine is a frequent chief complaint of patients in the emergency department. A wide range of treatments are used for acute migraine. Objective: This study aimed to compare the therapeutic effects of a combination of metoclopramide + dexamethasone with those of ketorolac for treatment of acute migraine in the emergency department. Method: This quasi-experimental study enrolled patients identified as migraine headache cases admitted to the emergency departments of Shohadaye Tajrish and Sina hospitals, Tehran, Iran. The patients were divided into two groups and treated with either 8 mg Dexamethasone + 10 mg Metoclopramide or 60 mg ketorolac, and then compared regarding the rate of pain control based on visual analogue scale (VAS) on arrival and 1 and 2 hours afterward. Results: Overall, 86 patients were recruited, of whom 50 were male (58.1%). Their mean age was 37.6 ± 10.3 years. Thirty-five (40.7%) were in the ketorolac group and 51 (59.3%) were in the dexamethasone + metoclopramide group. Treatment success was defined as a reduction of at least 3 points in pain severity in comparison to the admission time. One hour after administration of medications, the reported pain intensity was 4.7 ± 2.0 and 6.2 ± 2.3 in ketorolac group and dexamethasone + metoclopramide group, respectively. By the second hour, pain intensity was 3.4 ± 1.2 and 2.9 ± 1.3 in ketorolac group and dexamethasone + metoclopramide group, respectively. The two groups did not show a significant difference in terms of the reported pain at this time (p= 0.04). Conclusion: Based on our findings, the pain reduction time was relatively shorter for ketorolac in acute migraine, but the final response was identical in the two groups.
2. Farhadi Z, Alidoost S, Behzadifar M, Mohammadibakhsh R, Khodadadi N, Sepehrian R, et al. The Prevalence of Migraine in Iran: A Systematic Review and Meta-Analysis. Iran Red Crescent Med J. 2016;18(10):e40061.
3. Zhang Y, Parikh A, Qian S. Migraine and stroke. Stroke Vasc Neurol. 2017;2(3):160-7.
4. Antonaci F, Ghiotto N, Wu S, Pucci E, Costa A. Recent advances in migraine therapy. Springerplus. 2016;5:637.
5. Marmura MJ, Silberstein SD, Schwedt TJ. The Acute Treatment of Migraine in Adults: The American Headache Society Evidence Assessment of Migraine Pharmacotherapies. Headache. 2015;55(1):3-20.
6. Phueanpinit P, Pongwecharak J, Sumanont S, Krska J, Jarernsiripornkul N. Physicians' communication of risks from non-steroidal anti-inflammatory drugs and attitude towards providing adverse drug reaction information to patients. J Eval Clin Pract. 2017 Dec;23(6):1387-94.
7. Orr SL, Friedman BW, Christie S, Minen MT, Bamford C, Kelley NE, et al. Management of Adults With Acute Migraine in the Emergency Department: The American Headache Society Evidence Assessment of Parenteral Pharmacotherapies. Headache. 2016;56(6):911-40.
8. Marmura MJ, Silberstein SD, Schwedt TJ. The acute treatment of migraine in adults: the american headache society evidence assessment of migraine pharmacotherapies. Headache. 2015;55(1):3-20.
9. Singh 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):1223-33.
10. Donaldson D, Sundermann R, Jackson R, Bastani A. Intravenous dexamethasone vs placebo as adjunctive therapy to reduce the recurrence rate of acute migraine headaches: a multicenter, double-blinded, placebo-controlled randomized clinical trial. Am J Emerg Med. 2008;26(2):124-30.
11. Friedman BW, Corbo J, Lipton RB, Bijur PE, Esses D, Solorzano C, et al. A trial of metoclopramide vs sumatriptan for the emergency department treatment of migraines. Neurology. 2005;64(3):463-8.
12. Loder EW. Review: intravenous metoclopramide is better than placebo for reducing pain in acute migraine in the emergency department. ACP J Club. 2005;142(3):77.
13. Colman I, Brown MD, Innes GD, Grafstein E, Roberts TE, Rowe BH. Parenteral metoclopramide for acute migraine: meta-analysis of randomised controlled trials. BMJ. 2004;329(7479):1369-73.
14. Friedman BW, Adewunmi V, Campbell C, Solorzano C, Esses D, Bijur PE, et al. A randomized trial of intravenous ketorolac versus intravenous metoclopramide plus diphenhydramine for tension-type and all nonmigraine, noncluster recurrent headaches. Ann Emerg Med. 2013;62(4):311-8.e4.
15. Friedman BW, Garber L, Yoon A, Solorzano C, Wollowitz A, Esses D, et al. Randomized trial of IV valproate vs metoclopramide vs ketorolac for acute migraine. Neurology. 2014;82(11):976-83.
16. Friedman BW, Mulvey L, Esses D, Solorzano C, Paternoster J, Lipton RB, et al. Metoclopramide for acute migraine: a dose-finding randomized clinical trial. Ann Emerg Med. 2011;57(5):475-82.e1.
17. Singh 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):1223-33.
18. Colman I, Friedman BW, Brown MD, Innes GD, Grafstein E, Roberts TE, et al. Parenteral dexamethasone for acute severe migraine headache: meta-analysis of randomised controlled trials for preventing recurrence. BMJ. 2008;336(7657):1359-61.
19. Shahrami A, Assarzadegan F, Hatamabadi HR, Asgarzadeh M, Sarehbandi B, Asgarzadeh S. Comparison of therapeutic effects of magnesium sulfate vs. dexamethasone/metoclopramide on alleviating acute migraine headache. J Emerg Med. 2015;48(1):69-76.