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


Therapeutics

Intranasal lidocaine relieved acute migraine pain

ACP J Club. 1997 Jan-Feb;126:17. doi:10.7326/ACPJC-1997-126-1-017


Source Citation

Maizels M, Scott B, Cohen W, Chen W. Intranasal lidocaine for treatment of migraine. A randomized, double-blind, controlled trial. JAMA. 1996 Jul 24/31;276:319-21.


Abstract

Objective

To determine the effectiveness of intranasal lidocaine in patients with acute migraine.

Design

Randomized, double-blind, placebo-controlled trial.

Setting

Urgent care department in California, USA.

Patients

81 patients (median age 42 y, 83% women) who were > 18 years of age, who fulfilled the criteria of the International Headache Society (IHS) for migraine with or without aura, and whose present headache was of at least moderate intensity. Exclusion criteria were severe headaches occurring > once per week, current headache lasting > 3 days, or allergy to lidocaine.

Intervention

Patients were allocated in a 2:1 ratio to a 4% solution of intranasal lidocaine (n = 53) or saline placebo (n = 28). Patients were monitored for 15 minutes; if relief was inadequate, rescue medication was administered.

Main outcome measures

Reduction in headache pain of ≥ 50% within 15 minutes of treatment, reduction in nausea and photophobia, use of rescue medication, relapse of headache, and change in disability score.

Main results

More patients who received lidocaine had a reduction in headache pain of ≥ 50% within 15 minutes than did patients who received placebo (55% vs 21%, P = 0.004). {This absolute risk improvement of 34% means that 3 patients would need to receive lidocaine (compared with placebo) for 1 additional patient to have a reduction in pain intensity of ≥ 50% within 15 minutes of treatment (NNT), 95% CI 2 to 9; the relative risk improvement was 155%, CI 30% to 454%.}* More patients who received lidocaine had reductions in nausea (P = 0.03) and photophobia (P = 0.001) than did patients who received placebo. Rescue medication was required in the urgent care department by 28% of patients who received lidocaine compared with 71% of patients who received placebo (P < 0.001) {absolute risk reduction 43%; NNT 3, CI 2 to 5; relative risk reduction 60%, CI 36% to 76%}.* Rescue medication was required at home by an additional 54% of patients who received lidocaine and 67% of patients who received placebo (P = 0.67) {CI for the 13% absolute difference -30% to 45%}.* Among patients with initial relief of headache, the groups did not differ for relapse (42% vs 83%, P = 0.17) {CI for the 41% absolute difference -3% to 67%}.* The mean disability score was similar between groups (1.6 vs 2.0, P = 0.08).

Conclusion

Intranasal lidocaine provided relief within 15 minutes of administration to 55% of patients with acute migraine.

Source of funding: No external funding.

For article reprint: Dr. M. Maizels, Department of Family Practice, Southern California Permanente Medical Group, 5601 De Soto Avenue, Woodland Hills, CA 91365, USA. FAX 818-719-3291.

*Numbers calculated from data in article.


Commentary

Headache is the most common neurologic disorder encountered by primary care physicians in ambulatory care. Many physicians are unfamiliar with the IHS criteria for migraine without aura, which is perhaps forgivable because many neurologists find the IHS classification scheme unsatisfactory for everyday use (1). I would be hard pressed to categorize even half of my patients with severe headaches within the neatly segregated IHS framework. This is partly because the more severely a headache is graded by the patient, the more likely it is to be accompanied by nausea and visual distress.

I have been unable to find an appropriate use in my practice for the intranasal lidocaine treatment protocol. Treated patients are no more likely to function better in their daily lives than are untreated patients, and the patient must be able to lie down to use the medication, which would be difficult to arrange at work. "Rescue" medication was needed by 28% of treated patients in urgent care and by an additional 54% of treated patients after they got home. Finally, treated patients were no less likely than control patients to have a relapse, usually within 1 hour.

The nature, causes, and treatments of migraine puzzled Hippocrates and no doubt the physicians who treated Caesar, Kant, and Freud for their headaches (2). Anti-depressants, serotonin inhibitors, β-adrenergic receptor blockers, calcium channel blockers, vasoconstrictors, and anticonvulsants have all been used to treat migraine. Still, many patients have severe pain for prolonged periods, and it seems pointless to assure them that "nothing serious" was found on a magnetic resonance imaging scan. Patients with migraine provide a critical test of the communication skills, empathy, and psychological insight of their caregivers. Among the most satisfying experiences in medical practice are the opportunities to improve the quality of life for these patients by providing counseling and behavioral modification measures that have been used for centuries by our medical predecessors.

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


References

1. Hopkins A. Clinical Neurology: A Modern Approach. Oxford: Oxford University Press; 1993:115-7.

2. Sacks O. Migraine. Berkeley, CA: University of California Press; 1992:1.