NeurologyIntravenous sodium valproate versus prochlorperazine for the emergency department treatment of acute migraine headaches: A prospective, randomized, double-blind trial☆,☆☆,★,★★
Introduction
Migraine headache is a common presenting complaint to the emergency department. The management of these patients presents a therapeutic challenge in attempting to provide pain relief while minimizing time spent in the ED. Numerous therapies have been tried, including narcotics, antiemetics, phenothiazines, triptans, ergot alkaloids, and nonsteroidal anti-inflammatory drugs.1, 2, 3, 4, 5, 6, 7 Among these, intravenous prochlorperazine is one of the most common and has been shown to be superior to placebo in randomized clinical trials.1, 8 However, the efficacy of prochlorperazine might be limited because of its sedative and extrapyramidal effects.
Recently, there has been increasing interest in sodium valproate, an antiepileptic agent that has shown some usefulness in the prophylactic treatment of migraine headaches.9 Several case series have revealed significant improvement in patients treated with intravenous sodium valproate.10, 11, 12 In the only prospective randomized trial, sodium valproate demonstrated similar effectiveness as that provided by the combination of dihydroergotamine and metoclopramide in the treatment of acute migraine headaches.13
The purpose of the present study was to compare the efficacy of intravenous sodium valproate with that of prochlorperazine for the initial ED treatment of migraine headaches. Our null hypothesis was that there would be no difference in visual analog scale (VAS) scores for pain, nausea, or sedation between the 2 agents.
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Materials and methods
This was a randomized, controlled, double-blind study to evaluate the efficacy of intravenous sodium valproate when compared with prochlorperazine for the ED treatment of acute migraine headaches. The medical center's institutional review board for protection of human subjects approved the study. Written informed consent was obtained from all participants.
The study was conducted in the ED of a tertiary care medical center that serves beneficiaries of active duty and retired military personnel
Results
Between January 2002 and August 2002, 40 patients were enrolled in the study. One patient was dropped from the sodium valproate group because the data were incorrectly collected with a verbal analog scale rather than a VAS. On this scale, the patient, a woman, demonstrated only minimal improvement in pain (8/10 to 7/10) and required rescue medication (Figure 1).
Baseline data, including pain, nausea, sedation, age, and sex are represented in
Discussion
Migraine headache is a common presentation to the ED. Currently, there is no criterion standard for abortive treatment in the ED. The optimal therapy would work quickly and have no significant side effects so that patients can obtain relief from their symptoms and be able to be discharged from the ED in an expedited fashion. Because the cause of migraine headaches remains unknown, many different classifications of medicines have been tried with varying success.
Prochlorperazine, a phenothiazine,
Acknowledgements
Author contributions: SM, TF, and DAT conceived and designed the trial and obtained research funding. TF and DAT supervised the conduct of the trial and data collection. RHR provided statistical advice on study design, and both RHR and DAT analyzed the data. DAT drafted the manuscript, and all authors contributed substantially to its revision. DAT takes responsibility for the paper as a whole.
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2019, Neurologic ClinicsCitation Excerpt :Multiple neuroleptics are likely effective for migraine, with most available data focusing on outcomes in the ED or outpatient infusion settings.37 Prochlorperazine IV 10 mg is effective for acute migraine compared with placebo,67 sumatriptan injection,68 IV hydromorphone 1 mg,69 and IV sodium valproate 500 mg.70 Silberstein and colleagues71 reported droperidol intramuscular doses of 2.75, 5.5, and 8.25 mg/dose were significantly more effective than placebo for acute migraine.
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The views expressed in this article are those of the authors and do not reflect the official policy or position of the Department of the Navy, Department of Defense, or the United States Government.
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Presented at the American College of Emergency Physicians Research Forum , Seattle, WA, October 2002.
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The Chief, Bureau of Medicine and Surgery, Navy Department, Washington, DC, Clinical Investigation Program, sponsored this report (CIP No. S01-096), as required by NSHSBETHINST 6000.41A. This study was supported by a grant from the Clinical Investigations Department, Naval Medical Center San Diego.
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Reprints not available from the authors.