Review: intravenous metoclopramide is better than placebo for reducing pain in acute migraine in the emergency department.

and commentary also appear in ACP Journal Club. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . For correspondence: Dr B H Rowe, University of Alberta, Calgary, Alberta, Canada. [email protected] Source of Funding: Canadian Institute of Health Research and Canadian Association of Emergency Physicians Research Consortium. Metoclopramide for acute migraine* Outcomes at 1 week Number of trials (n) Comparison Weighted event rates RBI (95% CI) NNT (CI) Reduction in headache pain 3 (185) Metoclopramide v placebo 56% vs 31% 80% (1 to 221) 4 (3 to 44) Odds ratio (CI) 2 (161) Metoclopramide v other AEs 0.39 (0.18 to 0.87) Complete relief of headache 1 (62) Combination metoclopramide v other AMs 7.79 (1.79 to 33.86) *Abbreviations defined in glossary; weighted event rates, RBI, NNT, and CI calculated from data in article using a random effects model. Not significant. Commentary M etoclopramide avoids many perceived or actual liabilities of other current treatment choices for acute migraine. It also provides relief of pain and other such migraine associated symptoms as nausea and vomiting. These virtues explain the enduring popularity of metoclopramide for treating migraine in the ED setting. Colman et al provided a good summary of evidence of the effect of metoclopramide. Although the results show a reduction in pain that favours metoclopramide over placebo, the duration of effect and rate of headache relapse is not known. Metoclopramide alone does provide definitive treatment for some patients; however, 3 of 4 patients on average will require alternative or adjunctive treatment. The severity of the migraine should dictate the approach to treatment in the ED. Ketorolac, sumatriptan, dihydroergotamine, chlorpromazine, prochlorperazine, and dexamethasone with or without metoclopramide can be considered for treatment of migraine in the ED. The tantalising question of whether metoclopramide might outperform sumatriptan remains unanswered because the single study that reached this conclusion was low quality and lacked a placebo group. Some evidence supports the use of oral metoclopramide for acute migraine; however, the Food and Drug Administration recently rejected an application for an oral sumatriptan-metoclopramide combination product, stating concerns about long term safety. This should temper enthusiasm for wide scale use of metoclopramide. Elizabeth W Loder, MD Spaulding Hospital, Boston, Massachusetts, USA 1 Pryse-Phillips WE, Dodick DW, Edmeads JG, et al. CMAJ 1997;156:1273–87. 2 Prozen announces receipt of not-approvable letter for MT 100. www.pozen.com/product/mt100.asp (accessed 28 Jan2005). THERAPEUTICS 83 EBM Volume 10 June 2005 www.evidence-basedmedicine.com group.bmj.com on June 18, 2017 Published by http://ebm.bmj.com/ Downloaded from