Don’t Dilaudid for Headaches

What’s the most common Emergency Department treatment for “migraine” in U.S. Emergency Departments? If you guessed one of our respected go-to medications – metoclopramide, prochlorperazine, ketorolac, or such ilk – you’re be wrong. It’s friggin’ hydromorphone (Dilaudid). Ask for it by name. It starts with a “D”, and your doctor will know what you’re talking about.

For what it’s worth (hopefully), these data are out of date – coming from the 2010 National Hospital Ambulatory Medical Care Survey in an article published in 2014.  In their report, over half of patients treated for headache in the Emergency Department received opiate therapy, and hydromorphone led the pack. But, if hydromorphone is so widely used, are the rest of us responsible adults missing something?


This is a randomized, double-blind trial in which patients with migraneous headache in the Emergency Department were treated with either hydromorphone or prochlorperazine intravenously. The dose for hydromorphone was 1mg and the prochlorperazine 10mg, with those receiving prochlorperazine concurrently given diphenhydramine 25mg. The primary outcome was headache relief at 2 hours, as measured by patient reported symptoms and by any use of rescue medications, and patients could receive a second dose of the active study medication at the 1 hour mark.

These authors enrolled 127 patients, and at one hour, 15% of the prochlorperazine cohort still had severe or moderate headache, while 48% of the hydromorphone cohort reported the same. Similar absolute magnitudes of patients in the hydromorphone cohort requested a second dose of medication or required use of an off-protocol rescue medication. Then, the study was stopped – they expected to enroll 208, but a pre-planned analysis after 120 required the study be terminated with respect to the observed treatment difference.

And, that’s what I’d suggest be done in this case to hydromorphone use for headache – terminated. I hope the next time a report is published regarding the medications used for acute headache in the Emergency Department, hydromorphone has virtually disappeared from the list.

“Randomized study of IV prochlorperazine plus diphenhydramine vs IV hydromorphone for migraine”

3 thoughts on “Don’t Dilaudid for Headaches”

  1. Thanks very much for your review of this article, another solid step to banish the use of narcotics for migraines. Hopefully one day we as EM physicians will equate narcotics for migraines as we do Ipecac for ingestions.

    A neurologist taught me this regimen back in 1998 and it is has served me well throughout my career:

    Ketorolac 30mg IV
    Diphenhydramine 25mg IV
    Metoclopramide 10mg IV
    1000cc NS Bolus

    This regimen has served my patients well many many times, and I have yet to see any tardive dyskinesia from it.

    Many thanks for your superb work,

    1. As good as any of the various options out there! Thanks for sharing. I universally used droperidol until its disappearance, but now I’ve switched to prochlorperazine.

      Little evidence supports co-administration of diphenhydramine with metoclopramide, but on the spectrum of harms or costs it will be low.

  2. Thanks to you both for this. I have stopped using narcotics for headache since residency (’95 grad). I do like narcotics for acute pain, I won’t lie, but for headaches, I wholeheartedly agree with you both.

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