Perusing the Literature (PTL): Haloperidol for Migraines

Introducing the newest blog section – Perusing the Literature (PTL). This section includes summaries of recent articles that residents and attendings have stumbled across that have raised an eyebrow. These monthly posts are meant to spark a discussion and do not represent a change in the standard of care (unless otherwise noted).

Let’s get the ball rolling!

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November 2015: Haloperidol for Migraines

The Article: Gaffigan ME, et al. A Randomized Control Trial of Intravenous Haloperidol vs. Intravenous Metoclopramide for Acute Migraine Therapy in the Emergency Department. J Emerg Med. 2015 Sep;49(3):326-34.

The One-Liner: Intravenous haloperidol appears to be as safe and effective as metoclopramide for the ED treatment of migraine headaches.

Background: Headache accounts for 2–5% of ED visits and is the 5th most common ED complaint. Current first-line ED therapies include dopamine receptor antagonists such as prochlorperazine and metoclopramide, often with diphenhydramine. Studies have shown these medications to be safe and more effective than opiates, NSAIDs, and sumatriptan. Haloperidol is another dopamine antagonist and has been reported to be effective in the treatment of migraine headaches.

Methods: This was a prospective, double-blinded, randomized, controlled trial at a single emergency department of patients presenting with migraine headache. Each subject was given a 1L normal saline bolus and a baseline ECG completed. Diphenhydramine 25mg IV was administered, followed by the study medication – metoclopramide 10mg IV or haloperidol 5mg IV. Pain, nausea, restlessness, and sedation were assessed at 0, 20, 40, 60, and 80 min. After 80 min, the subject was either discharged home or offered rescue therapies at the discretion of the treating physician. Prior to discharge, a second ECG was obtained. Subjects were to be contacted at 48-hours after discharge and were asked if they were happy with the medication received, and if they had any recurrent or persistent symptoms specifically, headache, sleepiness, restlessness, agitation, nausea, vomiting, or chest pain.

Results:

  • A total of 64 patients were enrolled – 31 randomized to haloperidol and 33 metoclopramide.
  • Mean reduction in pain from baseline was statistically and clinically significant for both haloperidol and metoclopramide groups.
  • Pain scores between the groups did not differ at baseline, at the last measurement, in the magnitude of the pre-post treatment change, or in the time to pain relief.
  • More patients in the metoclopramide group required a rescue medication for pain relief (p < 0.02).
  • Sleepiness was statistically more common in the group that was to receive haloperidol (p < 0.02). There were no other differences between the groups in any of the other side-effect questions asked (nausea, restlessness, chest pain).
  • Mean QTcs were equal and normal in the two groups and did not change after treatment for either group.
  • 43/64 patients were reached for 48-hour follow up. Restlessness reported more by the haloperidol group (43% vs 10%, p < 0.015).

Limitations:

  • The study was single centered and admittedly small.
  • The study used a convenience sample, subjects were relatively young and mostly female (81%).
  • Post-treatment ECGs were obtained in only 45% of subjects.
  • Telephone follow up was obtained in only 67% of subjects.

 

Posted by Adam Janicki, MD, PGY4

Reviewed by Gita Pensa, MD, Clinical Assistant Professor, Department of Emergency Medicine

4 thoughts on “Perusing the Literature (PTL): Haloperidol for Migraines

  1. Great section. I’m not sure I understand the restlessness 48 hours after the index visit? Why would haloperidol cause such lasting effects–if we can even begin to infer causation from this study.

    • The half life is 14-36 hours for haloperidol, thus agitation, restlessness and akathisia (haldol’s most common CNS side effects) can last for a more prolonged period that other drugs.

  2. Of course, sometimes the restlessness (“I’ve got to get out of here NOW!!”) works in our favor…Perhaps for selected patients??

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