Intravenous prochlorperazine plus diphenhydramine was found to be superior to IV hydromorphone for the treatment of migraine pain in the emergency department setting, according to a new study published in the journal Neurology.

The double-blind study was conducted at 2 emergency departments (ED) in New York City. Participants were randomized to either hydromorphone 1mg (n=64) or prochlorperazine 10mg plus diphenhydramine 25mg (n=62). Diphenhydramine was administered in order to prevent akathisia, a side effect of IV prochlorperazine. 

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The primary outcome of sustained headache relief (mild or no headache within 2 hours of drug administration maintained for 48 hours) was achieved by 60% (n=37) of patients in the prochlorperazine group versus 31% (n=20) of patients in the hydromorphone group (difference 28%, 95% CI 12–45, number needed to treat 4, 95% CI 2–9).

“Ours is the first randomized study to demonstrate that it is not appropriate to administer the opioid, hydromorphone, as a first line therapy for patients with migraine,” said lead researcher Benjamin Friedman, MD, MS, who is also Professor at Albert Einstein College of Medicine and Vice-Chair for Clinical Investigation in the Department of Emergency Medicine at Montefiore.

The researchers followed up with the study participants at 48 hours, 1 and 3 months after their ED visits and both groups had similar long-term outcomes, including comparable number of headache days and return ED visits. Dr. Friedman said, “Our study clearly shows there is no benefit to using the opioid hydromorphone as first-line treatment for most migraine patients in the ED.”

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