Current issues of ACP Journal Club are published in Annals of Internal Medicine


Therapeutics

Rectal prochlorperazine alleviated migraine pain

ACP J Club. 1995 Jan-Feb;122:6. doi:10.7326/ACPJC-1995-122-1-006


Source Citation

Jones EB, Gonzalez ER, Boggs JG, Grillo JA, Elswick RK Jr. Safety and efficacy of rectal prochlorperazine for the treatment of migraine in the emergency department. Ann Emerg Med. 1994 Aug;24:237-41.


Abstract

Objective

To determine the efficacy and safety of rectal prochlorperazine in alleviating pain in patients with acute migraine presenting to the emergency department.

Design

Randomized, double-blind, placebo-controlled trial with a 24-hour follow-up.

Setting

Emergency department of a university-affiliated hospital.

Patients

20 patients (mean age 30 y, 95% women) with a diagnosis of migraine based on International Headache Society criteria. Exclusion criteria were age ≤ 17 years, phenothiazine intolerance, current treatment with phenothiazines or butyrophenones, history of drug-seeking behavior, pregnancy or lactation, unstable vital signs (systolic blood pressure < 90 mm Hg, orthostatic hypotension, or temperature > 37.7 °C), and headache presumed not to be of vascular origin. Follow-up was 100%.

Intervention

Patients were allocated to prochlorperazine suppository, 25 mg (n = 10), or placebo (n = 10).

Main outcome measures

Pain intensity measured with a 10-point verbal analog scale (0 = complete pain relief, 10 = worst pain imaginable); level of alertness measured with a 4-point scale (0 = awake and alert, 4 = deep sleep), vital signs, and adverse events. All outcomes were measured before treatment and 30, 60, and 120 minutes after treatment.

Main results

More patients who received prochlorperazine than those who received placebo achieved a 50% reduction in pain intensity from baseline (P = 0.016) (Table). The mean pain intensity score of the prochlorperazine group was lower than that of the placebo group (2.3 vs 5.1, P = 0.018). Difference between groups in pain intensity at 30 and 60 minutes, level of alertness, and vital signs did not reach statistical significance. No adverse events were noted.

Conclusion

Rectal prochlorperazine was safe and effective in alleviating pain within 2 hours of administration in patients with migraine who presented to the emergency department.

Source of funding: SmithKline Beecham.

For article reprint: Dr. E.R. Gonzalez, Box 533, Medical College of Virginia (MCV) Station, Richmond, VA 23298, USA. FAX 804-779-0837.


Table. Prochlorperazine suppository vs placebo for migraine pain relief (pain intensity score ≤ 5 or a 50% reduction in pain intensity from baseline)*

Outcomes at 2 h Prochlorperazine Placebo RBI (95% CI) NNT (CI)
Migraine pain relief 100% 50% 100% (12 to 306) 2 (1 to 7)

*Abbreviations defined in Glossary; RBI, NNT, and CI calculated from data in article.


Commentary

Migraine is the most common neurologic disorder encountered in non-neurologic practice. It is also a dreadful problem for the patient, whose quality of life is affected and who will often be viewed by professionals and friends as a complainer. Thus, many persons who have migraines postpone seeking help and then visit the emergency department. This imaginative study sought to find a way for patients with migraine to successfully treat themselves at home or work, thus avoiding the inconvenience (and cost) of emergency care.

The study results are interesting, confirming the efficacy of antiemetic agents in migraine, but the goal of avoiding an emergency department visit is probably unattainable. The decision to go to the emergency department for migraine treatment often has social and psychological antecedents that are surprisingly independent of the perceived severity of the attack.

For some patients with migraine, gastrointestinal distress is a bigger problem than head pain, and this is often exacerbated by medications such as nonsteroidal anti-inflammatory drugs. For these patients, metoclopramide, chlorpromazine, or prochlorperazine may be all that is needed for the acute attack. Although acute dystonias may occur with prochlorperazine, the drug is certainly a reasonable first-line approach for self-treatment in patients who cannot tolerate oral metoclopramide abortive pharmacotherapy with or without analgesics, using ergot alkaloids or sumatriptan for treatment failures.

Are these study results generalizable? The 50% placebo response rate certainly is! Moreover, the proof that most patients do not need narcotics to abort the attack confirms practice experience. Still, we cannot tell from the 2-hour study duration how many relapses occurred or when they developed. How many patients fell asleep when they got home? This effect would make self-treatment at work with this approach unrealistic and driving potentially hazardous. I also believe that in the year 3000, many pharmacologic treatments will still exist for this disorder that, perhaps more than any other, reflects the humanity of its victims and those who care for them (1).

Matthew Menken, MD
Robert Wood Johnson Medical SchoolSomerset, New Jersey, USA


Reference

1. Sacks O. Migraine: Understanding a Common Disorder. Berkeley: University of California Press; 1985.