Metoclopramide versus hydromorphone for the emergency department treatment of migraine headache

We conducted a retrospective cohort study to compare the effects of metoclopramide versus hydromorphone for the initial emergency department treatment of migraine headache at an urban teaching hospital. The primary outcome measure was the mean difference in the subjects' self-reported pain scores before and after the administration of the initial medication treatment. We also estimated crude and adjusted relative risks (using Poisson multivariate regression modeling) to assess and control potential confounding by age, gender, race, and pain score before initial medication. Two hundred subjects were included, with 51 (25.5%) receiving intravenous or intramuscular hydromorphone, 95 (47.5%) receiving intravenous metoclopramide, and 54 (27.0%) receiving 1 of several other medications. Using a standardized pain scale of 0 to 10, mean pain score reductions were 2.3 points for hydromorphone, 3.7 points for metoclopramide, and 2.8 points for all other medications combined (P <.001). When comparing metoclopramide versus hydromorphone, the crude relative risk for pain reduction of 3 or more points was 1.76 (95% CI, 1.12-2.75, P =.01), and the adjusted relative risk was 1.60 (95% CI, 0.84-3.03, P =.15). Metoclopramide also resulted in less use of rescue medications, faster times to discharge, and no difference in the frequency of adverse reactions. Perspective: Metoclopramide appears to be an effective initial medical treatment for migraine headaches in the emergency department setting, but its pharmacologic mechanism remains incompletely understood A double-blinded, randomized, controlled trial comparing standard dosages of hydromorphone versus metoclopiramide will be needed to definitively determine which medication is more effective. (c) 2008 by the American Pain Society.