Opioids Should Be Avoided for Individuals with Migraine Who Come to Emergency Department

New research supports avoiding the use of opioids for patients who come to the emergency department (ED) with migraine. The study, which was presented at the American Headache Society (AHS) 59th Scientific Meeting in June 2017, shows that patients who arrived in the ED with acute migraine and received intravenous prochlorperazine were twice as likely to have headache relief within 2 hours as those who received opioids.

The randomized, double-blind trial was stopped early by the data monitoring committee because they found the results to be so beneficial.

“Basically, patients who got prochlorperazine were twice as likely to have a good outcome, and those who got hydromorphone (opioids) were twice as likely to have a side effect,” lead author Benjamin W. Friedman, MD told Medscape Medical News.

“There’s no place for intravenous opioids in the treatment of migraine,” he said.

The study, which involved patients who presented in two EDs in New York City with moderate or severe migraine, showed that 60% of those who received prochlorperazine had relief within 2 hours for at least 48 hours. This compared to just 31% who received the opioid, hydromorphone, and experienced similar relief.

  • Bob Krebs
    Posted at 12:25h, 21 July Reply

    I must be quite the outlier! If I have a 7 1/2 migraine or above, a 1 mg shot of hydromorphone will kill my migraine within 15 minutes, with no rebound. The few times I had that dosage given via IV, the migraine was gone in 5 minutes or less. Also, no rebound and no high. Though with the IV, I could actually feel the drug go through my body to the migraine site and do its work! Basically, a warm flow through my blood vessels. For me, when the drug hit the migraine site, the site became very warm and it felt like the drug was “chewing” on the pain, and then it was gone!

    Please note that I did not get another migraine until a another triggering event, which could be days or weeks!

    I realize everyone is different, but given my experience, I have a hard time understanding this study result!

  • Cynthia
    Posted at 13:00h, 21 July Reply

    Completely disagree! I’ve had migraines since 13 and I am now 57. Only have to go to ER now about twice a year. In my 30s visited more frequently. The only thing that relieved my pain was Demerol with phenegran. It took the pain level down and let me go home and sleep. When they gave me no narcotics did not take pain level down. Just make me tierd with no sleep. I’m not an abused of opiates but when u have a migraine that lasts over three days that is all that works intravenously. Recently had to go to ER for migraine over 3 days. Did not get opioids and went home 300 dollars less in the bank, more in pain than when I got there because I was treated rudely. I’m sorry, patients sometimes know better than doctor what works for them and what doesn’t. In studies, there is the exception that doesn’t work on all patients in study. This article infuriates me saying that opioids should not be given to migraine patients in ER. Life needs to go on, not lay in bed missing out on work because u can’t get an emergency remedy so u can continue on with your daily activities.

    • Carolyn Meadows
      Posted at 12:36h, 31 July Reply

      Demerol/ phenegran is my savior but ER is being stingy with it lately. Two weeks ago went to ER and gave me Stadol/phenegran which made me high but still had pain. They told me Demerol isn’t being used as much cause of causing heart issues.

  • Patricia
    Posted at 13:22h, 21 July Reply

    I agree that IV Opiods alone for the treatment of Migraines in the ER are not the most effective treatment but when combined with other medications such as Toradol and a Steriod, they work very well. I understand the need to be cautious about administering Opiods as a first line treatment but I think doctors need to understand that most people would rather NOT have to go to the ER for treatment and wait hours, in pain. By the time they make the decision to go that route their pain is usually well above the scale of 1-10 and usually unbearable. While ER doctors may not be able to heal migraine patients they should certainly want to lessen their pain as efficiently and quickly as possible.
    Having suffered with Migraine Disorder for many years and having had to go to the ER for treatment when nothing else worked, I have found it so frustrating that there is no set protocol for ER doctors to treat migraines.

    • R. L. Hudak
      Posted at 16:39h, 31 July Reply

      Not only is there no set protocol, I have found over the years that ER physicians like to ‘try out’ different treatments. The last doctor that I saw gave me Haldol, which in turn, resulted in such serious side effects that I had to undergo additional treatment and miss three days of work. A small dose of Dilaudid, and I would have been on my way, no problem.

      In another case, I was told by a nurse that a pain rating of 10 means that my entire body is engulfed in flames, so could I please give her my true pain rating? I would hope that if I was on fire, they would not stop to ask for my pain rating. Wow.

  • Anonymous
    Posted at 01:04h, 25 July Reply

    This is my story…it’s not pretty,it’s graphic,but who would learn anything if I didn’t tell it? I have been diagnosed with chronic migraines,& cluster headaches. It took me 3 yrs to find a Dr. that would treat me,because of the “scare of the opioid’, I NEVER once asked for an opioid. I did my research,did the herbal remedies first,they didn’t work. I spent 3 miserable yrs waking up clutching my head in pain so horrible I couldn’t think,having to clutch my head & stomach(we all know what happens in the bathroom),good thing I had a garbage can cuz I was throwing up at the same time. I would throw up for hours,finally throwing up bile,by this time once it’s actually coming out of your nose as well & your shivering but sweating my daughter would call the ambulance. This happened over & over,etc..They would give me Zofran, didn’t work,I would then throw up in the ER for around 6 hrs before they finally would admit me. I didn’t stop throwing up until they gave me Promethazine every 8hrs, Zofran every 4hrs.
    Then came the tests,always on my stomach, the endless x-rays, the barium. They even brought in an Infectious Disease Doctor. All they found was a Hiatus Hernia, oh, & my stomach Doctors advice ,and I quote ” your stomach hates you” This was after the 5th stomach scope,I also had another scope done,thankfully I was put out for THAT one! A colonoscopy. They found nothing.
    I left my Primary Physician,I’d had enough. Found a new one who finally helped me,the first thing he said “good thing you didn’t have a brain tumor,or you would be dead” The second ” I’m not like other Doctors,I will help you”. He didn’t throw my three year journal at me & tell me to get out,I was having around 10 to up to 15 migraines a month. A Neurologist at The Cleveland Clinic did that to me. Dr. Arnold put me immediately on Sumatriptan100mg,Topiramate 50mg,Zofran 4mg ,& Promethazine12.5. Finally relief, I started to live my life again. But I want you,you can only take so much of these medications. Samaritan allows only 9 pills a month,they are not good for your heart & I had to be upped on the Topiramate to100mg twice a day,but it started messing with my eye sight. NO PILL you take comes without side effects,NOTHING. I’m down to 50mg a day. BUT I will soon be off both these medications! I have been for the past year getting Botox for chronic migraines,it has changed my life more than ANYTHING ELSE. I haven’t had to take ANY Sumatriptan,& my next Doctor visit will be down to 25 mg of Topiramate. It does take at least 3 sessions for the shots,it did for me,but I’ve only been to the ER one time, & that was at the beginning of the year. I highly recommend Botox for chronic migraines,if you had them like me you know what it is like. I haven’t had any cluster headaches. The first 6 months a headache will break threw but NOTHING like before.
    I’ve heard of this Prochlorperazine,why are you giving people a medicine that is a antipsychotic? ( medications for mental illness),my sister had bipolar disorder & schizophrenia so yes I understand mental illness,she was diagnosed at 10. I am a TRUE advocate for mental illnesses & the way people are treated.(my sister unfortunately committed suicide because of her illness).
    This medicine says it treats nausea IN TWO HOURS as well,no one,& I mean NO ONE wants to be in the ER waiting on a medication that takes 2hrs to work especially if you have a migraine & the side effects are horrific,- coma,vision loss,especially at night,rash,hives,fine,worm-like tongue movements,HEADACHE,(why give you something to make your headache worse!???),and the list goes on & on…& it’s NOT even approved by The FDA,for older patients who have behaviour problems with dementia. If your so worried why NOT give a NON Narcotic like a Toradol injection? Yes of course it has side effects but I’ve had shot & suffered none,& the side effects are not as frightening. At all.

  • Anonymous
    Posted at 12:30h, 31 July Reply

    Prochlorperazine is also known as compazine and is commonly used for nausea. It is not just used as an anti-psychotic. I find it sad that they have to find other ways to treat migraines because so many go to the ER claiming they have migraines when in fact they are just drug seeking. I’m a migraine sufferer but mine have been very controlled for several years. I have something I can take at the onset to stop one but I’ve only used it once in a couple of years. If you are a true migraine sufferer, you will understand how awful the pain is. So many complain when they haven’t a clue what a true migraine is.

  • Michelle
    Posted at 13:59h, 31 July Reply

    It’s one thing to say that this other drug should be tried first. Fine, I get it, the studies say it works better so why not. However, to say that opioids have NO place in treating migraine is absolutely nonsensical. If someone has gone through a decade of trying EVERY. SINGLE. THING. and gone all over the country looking for help, only to find they are part of the small group of people who just don’t respond, why should they have to suffer? Why not relieve that suffering? If you want to recommend trying that other med first, great, go for it. To say that its good results in studies means there’s no reason for opioids to be given is horrendous.

  • Angela
    Posted at 14:04h, 31 July Reply

    One of the last times I went to the ER the on call wanted to try a psych drug. I can’t remember the name. Needless to say it did not work and they ended up giving me the normal cocktail after that. My boyfriend took me home and I was out cold like normal no pain. Well a few hours later I was sleep walking unplugging everything in the house and talking nonsense. Everyone that goes to the ER for migraines are getting a bad wrap, it’s like almost immediately the doctor thinks you are an addict, it’s getting ridiculous. We don’t want to have this problem and be there in the first place let alone to have to prove you aren’t there to get high. People don’t understand there isn’t a “high” for people in real pain. We are there for help not rudeness and judgements. I know there are a ton of people that do go to get high and I don’t have the answers but come on.

  • R. L. Hudak
    Posted at 16:35h, 31 July Reply

    Thanks for making it more difficult for those with this debilitating disease to find even a moment of relief. The ER is absolutely the place for opioids as the ER’s function is to quickly and effectively treat emergency conditions. Opioids are not a long-term solution, nor should the ER be expected to offer a long-term solution. I find the results of this study laughable. Were the participants actual migraineurs or simply patients complaining of a headache? Just one more step backward for the millions who suffer daily with chronic migraine.

  • Nancy
    Posted at 18:04h, 31 July Reply

    Making such a generalized statement as oppose have NO place on the treatment of migraines in the ER is exactly why so many migraineers are treated as drug seekers when going to the ER. It may be true for many of those with migraines the compazine works betttr or many other non oppose medications but for many of us a cocktail of medications, which must include an opoid is the ONLY thing that works!!!!!!! I am so sick of seeing articles like this.

  • Anonymous
    Posted at 18:09h, 31 July Reply

    This is really dangerous to make such a blanket statement. Everyone processes drugs differently. Most major drugs are effective in only 25 to 60 percent of the population. There are over 2 million adverse effects reported annually in the United States. (This includes 100,000 deaths. ). Pharmocogenetics is the study of how drugs are broken down and processed by the liver. This drug is processed through the cyp 450 enzymes cyp2D6 and cyp 3A4. I can’t even process cyp2D6. I have had dangerous life threatening side effects from taking prescriptions processed by cyp 2D6. It is very unprofessional to say opioids do not belong in the treatment of migraine. They supposedly have a virtual reality app that can simulate a migraine. Maybe everyone responsible for this article should try that . I have actually thought I would rather die than endure the pain.

  • Denise
    Posted at 01:36h, 02 August Reply

    Are all these physicians the ones that get migraine, NO! Why do they have to mess with things that work. 40 years of migraines. Have used my own method of a pain pill, nausea pill and stool softeners (I call it bombing it out) to break those darn rebound cycle… and no waiting in ER, dreadful pain, nausea, and bright lights.

  • Dawna
    Posted at 17:05h, 02 August Reply

    I am a migraine sufferer of 22 years. All opioids ever did for my migraines is make it worse or give me a rebound headache from hell. There is one medication that works for me which is a very potent vasoconstrictor. I am a firm believer that opioids should not be used to treat migraines after my experiences with them.

  • Jo Smith
    Posted at 22:11h, 02 August Reply

    Oh my gosh!! I so agree with all the comments above. I have suffered since I was 7. I’m now 50. My headaches have changed so many times over the course of my life. I have seen multiple multiple specialist without much relief. The last neurologist I have seen doesn’t know what else to try. I recently was on my 10th day of a migraine. I finally went to our ER. The PA who saw me told me all about her history of migraines and how opioids are the last thing I need. She sat and lectured me said she would give me one treatment of this and no more. I am not a drug seeker. I haven’t been to the ER in months. I was furious. I was given benedryl, toridol and something for nausea. I left there feeling tired but still in pain. I knew what I needed but I was afraid to ask.

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