Which Parenteral Treatment Is Best for Acute Migraine?

Amy R. Tso, MD

A randomized, double-blind, comparative-efficacy trial suggests that intravenous valproate is inferior to both metoclopramide and ketorolac for treatment of acute migraine.

Treatment for acute migraine is a common reason for emergency department (ED) visits, where adequate therapy can prevent admission for symptom control. In this study, researchers randomized 330 patients presenting to a single ED with acute migraine to receive one of three parenteral therapies: valproate (1 g), metoclopramide (10 mg), or ketorolac (30 mg). Baseline pain severity on a verbal 0-to-10 scale was ≥7 in all enrolled patients. The primary outcome was improvement in pain severity 1 hour after treatment, with a between-group difference of 1.3 points representing a minimum clinically significant change. The authors performed an intention-to-treat analysis for each of the three pairwise comparisons.

Valproate recipients improved by 2.8 points, compared with 4.7 points for metoclopramide and 3.9 points for ketorolac. More valproate recipients required additional rescue medications (69%) compared with metoclopramide (33%) and ketorolac recipients (52%). Despite a 6% incidence of feeling “very restless” in the metoclopramide group (vs. 1% each in the valproate and ketorolac groups), a greater proportion of metoclopramide recipients would want to receive the same medication at a future ED visit for migraine compared with the other two groups (61%,vs. 26% valproate and 40% ketorolac).

Citation(s):

Friedman BW et al. Randomized trial of IV valproate vs metoclopramide vs ketorolac for acute migraine. Neurology 2014 Feb 12.