RANDOMIZED, PLACEBO-CONTROLLED EVALUATION OF PROCHLORPERAZINE VERSUS METOCLOPRAMIDE FOR EMERGENCY DEPARTMENT TREATMENT OF MIGRAINE HEADACHE

Study objective: To determine the comparative efficacy of IV metoclopr amide and prochlorperazine for the initial emergency department treatm ent of migraine headache. Design: Prospective, randomized, double-blin d, placebo-controlled trial. Setting: Military community hospital ED w ith an annual census of 75,000. Participants: Seventy consenting adult s from a convenience sample of patients presenting with migraine heada che similar to that experienced in at feast one prior episode. Exclusi on criteria were pregnancy, fever, signs of meningismus, altered senso rium, drug or alcohol use, oxygen saturation less than 90%, recent tra uma or seizure, ''worst headache,'' abnormal blood pressure, recent (w ithin 48 hours) use of metoclopramide or prochlorperazine, and allergy to metoclopramide or prochlorperazine. Interventions: In a random man ner, each subject received a 2-mL IV injection of identical-appearing fluid containing metoclopramide (10 mg), prochlorperazine (10 mg), or saline solution (placebo). No other analgesics or medications were adm inistered during the initial study period; rescue agents were administ ered by the choice of the treating physician after all data were colle cted. Measurements: Patients scored their nausea, pain, and sedation b efore receiving the 2-mL injections and at 30 minutes after injection. Ten-centimeter nonhatched visual analog scales were used far these me asurements, with distance from the left end (zero) calculated for each use. Clinically important successful treatment was defined a priori a s achievement of the following criteria: patient satisfaction and eith er a decrease of 50% or more in the 30-minute pain score (compared wit h the initial score) or an absolute pain score of 2.5 cm or less. Fail ure to achieve these criteria constituted treatment failure. Differenc es between groups were analyzed with the Kruskal-Wallis ANOVA and chi( 2) tests. Data are reported as frequency percentages and median values , with a two-tailed P value of .05 or less considered significant. Res ults: Nausea, pain, and sedation scores were similar in all three grou ps before therapy. Thirty minutes after treatment, pain scores differe d among those treated with prochlorperazine (1.1 cm), with metoclopram ide (3.9 cm), and with placebo (6.1 cm, P = .003). Clinical success oc curred more commonly after treatment with prochlorperazine (82%) than after metoclopramide (46%) or placebo (29%, P = .03). However, metoclo pramide and placebo scores did not differ (P = .14). Nausea tended to be improved after prochlorperazine, compared with metoclopramide or pl acebo, at 30 minutes (P = .64). Four patients (6%) returned to the ED for relapse of migraine headache within 24 hours (three in the placebo group and one in the metoclopramide group). Conclusion: IV prochlorpe razine relieves the headache and tends to improve nausea better than m etoclopramide in ED patients with acute migraine headache.