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For what it’s worth (hopefully), these data are out of date – coming from the 2010 National Hospital Ambulatory Medical Care Survey in an article published in 2014.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”