A Systematic Review and Network Meta-Analysis of Emergency Department Migraine Treatment
are a common presenting complaint to the emergency department (ED), and migraine
headaches are a common subtype, often refractory to many home treatments. Despite the
high prevalence of this disorder, enormous practice pattern variation exists in the
treatment of migraines in the ED, drawing from a wide array of medication classes.
Despite the large array of interventions,... read moremany have not been studied directly with first
line agents or placebo. Further, practice pattern often deviates from professional
society recommendations and it is possible this is due to lack of knowledge regarding
the effectiveness of interventions. In order to describe the comparative effectiveness
of these interventions, we undertook a systematic review and network meta-analysis. We
searched randomized controlled trials comparing non-oral interventions in adult ED
patients with migraines; of 2,392 articles, 40 studies met pre-determined inclusion
criteria for our final analysis. Where possible, we performed meta-analysis for pain
reduction 60 minutes after treatment. We employed a network meta-analysis to estimate
comparative effects that have not been investigated head to head in randomized
controlled trials. Secondarily, we attempted to examine the rates of adverse effects and
recurrence of headaches. Neuroleptics resulted in the largest reduction in mean pain
scores across all comparators with a mean 43.6 (95% CI 54.9, 32.3, I2=0%) point
reduction on a 100-point scale compared with placebo. Combinations of medications were
not superior to individual medications. Adverse events and headache recurrence were
unable to be pooled due to incomplete reporting and small numbers, but no observable
trends were noted regarding akathisia/restlessness and drowsiness between interventions.
We found that neuroleptics and antiemetics resulted in the most consistent pain
reduction in the first 60 minutes of ED treatment for acute migraine. Since combination
medications were not more effective than single interventions or placebo, empiric
administration of combination medications cannot be recommended for efficacy. We were
not able to analyze the possibility that the addition of antihistamines reduces adverse
effects due to the small number of outcomes and the small number of studies reporting
akathisia and restlessness. This research paves the way for future guidelines for ED
care to focus on ED specific populations by demonstrating the performance of migraine
treatments in this setting
Thesis (M.S.)--Tufts University, 2018.
Submitted to the Dept. of Clinical & Translational Science.
Advisor: Raveendhara Bannuru.
Committee: Raveendhara Bannuru, Timothy Mader, and Norma Terrin.
Keyword: Medicine.read less