A Troubling Mix: Migraine, Opioids, & The ER
Pain Management in Focus
If you suffer from migraine, there’s a decent you may have, at some point, gone into the emergency room (ER). You’d be far from alone; migraine attacks lead to no less than 1.2 million ER visits a year in the US, and in 25 percent of theses, an opioid drug, hydromorphone, is administered. However, there’s a problem; according to Dr. Benjamin Friedman of New York, NY’s Albert Einstein College of Medicine, “there have been no randomized, high-quality studies on its use for acute migraine.” 
This is what inspired Dr. Friedman and his colleagues to do exactly that; they wanted to assess the efficacy of hydromorphone for migraine in the ER setting. Knowing that opioids are highly addictive, they also wanted to get a sense of what happens after the visit; does the population of migraineurs who’ve been administered this drug end up developing dependency?
Based on their work, the researchers concluded that alternatives to opioids should be considered in the ER setting: that this class is not great for management of acute attack. How did they get there? Let’s take a look:
Opioids vs. Others
In order to assess how well hydromorphone works for migraine in the ER setting, Dr. Friedman and his colleagues compared its efficacy with that of a dopamine blocking drug, prochlorperazine in combination with diphenhydramine, which prevents restlessness.  (Dopamine is a brain chemical that’s often associated with pain and reward sensations.) They looked at 127 migraine patients from two emergency departments in New York City; via IV half were administered the standard dose of hydromorphone, while the rest were given prochlorperazine alongside diphenhydramine.
In these populations, they compared levels of sustained headache relief—defined as lack of or only mild headache without the need for additional drugs—within two hours after administration, and for up to 48 hours afterwards.  Overwhelmingly, the results showed diphenhydramine to be superior to hydromorphone, and, in fact, these were so robust, that the team determined they needed no more than the initial 127 participants to look at.
Here’s a quick breakdown of what they saw:
- Opioid Patients: In this population, approximately 31 percent (20 of 64) of the patients saw sustained headache relief. In addition, it was found that another 31 percent of these patients asked for more hydromorphone.
- Prochlorperazine Patients: Among those that were administered prochlorperazine (alongside diphenhydramine), a robust 60 percent (37 of 62 people) experienced relief for up to 48 hours. Tellingly, only 6 percent of this group asked for more of the drug.
Clearly, the standard first-line ER approach to migraine—the use of opioids—was found to be less effective than the alternative; “IV hydromorphone” they wrote “should not be used as first-line therapy.”  That said, it was encouraging for the authors that, based on follow-up at one month, the use of hydromorphone did not seem to elevate risk of long-term dependency in the research population.
Limitations & Implications
While these results quite plainly imply that dopamine blocking drugs are more effective than opioids in the ER setting, Dr. Freidman and the team did note that there are some limitations to their results. Some patients will not respond well to prochlorperazine and will still need opioid drugs. Also, as part of the study, the researchers looked at those who had not taken any sort of opioids in the month leading up to it. This implies that this population is less predisposed to forming opioid addiction, which may account for some of their results.
Still, there’s much to praise about a study like this. In the manner of good science, these researchers identified a problem and looked into it in a systematic way. Further, they’ve broadened the understanding of what works best for migraine management in the ER setting. While there’s much more to understand and explore, progress like this is encouraging for those that suffer with this difficult condition. It’s another step towards discovering the best means of managing—and even curing—migraine for good.
If you suffer from frequent migraine attacks, the team at Migraine Treatment Centers of America is ready to help. They employ the latest in techniques and technologies to help countless people find effective relief from suffering. Learn more about what they do by calling (855) 300-6822 today!
- “Skip Opioid Treatment For Migraine In The ER “. 2017. Consumer Healthday. Accessed December 28 2017. https://consumer.healthday.com/head-and-neck-information-17/migraine-news-477/skip-opioid-treatment-for-migraine-in-the-er-727534.html.
- Friedman, Benjamin W., Eddie Irizarry, Clemencia Solorzano, Alexander Latev, Karolyn Rosa, Eleftheria Zias, David R. Vinson, Polly E. Bijur, and E. John Gallagher. 2017. “Randomized Study Of IV Prochlorperazine Plus Diphenhydramine Vs IV Hydromorphone For Migraine”. Neurology 89 (20): 2075-2082. Ovid Technologies (Wolters Kluwer Health). doi:10.1212/wnl.0000000000004642.