Triptans in the ER

[tkim]

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Anyone use them? I don't, and never did in residency. But I wonder why not?

 

[Apollyon]

At my last job, one hospital in 4 (all in the same system) had them in the ED, so I used them. Otherwise, just the regular headache cocktail.

 

[Aesculapius]

I'm just an MS3, but I might speculate that by the time that a headache patient gets seen by an EP, the triptans probably aren't going to be particularly effective.

 

[Rendar5]

The reason not to use them is that they are inferior to IV compazine in terminating a migraine.

 

[Tornadoman84]

The reason not to use them is that they are inferior to IV compazine in terminating a migraine.

I'd like to see that study Rendar that shows IV compazine is superior to triptans. I think it would be helpful.

According to DynaMed, BOTH triptans and compazine are considered Level I evidence as agents with proven pronounced benefit. If you take a look at the AFP, they also consider triptans level A evidence (consistent, good quality patient-oriented evidence). So unless Rendar finds something, I don't see how one can say one drug is superior to the other.

The reason people may be using IV compazine rather than triptans is, like most things we do in medicine, because of how we trained. Triptans are relatively new and as non-neurologists we may be less comfortable giving a triptan (especially with its contraindications in patients with a history of MI, CVA, uncontrolled HTN). Triptans ($100-$200) also are WAY more expensive than compazine or reglan ($1-$3). There may be other reasons, but these are what come to mind. Any other thoughts?

 

[ORL10]

there is a prospective randomized trial comparing the two of these below:

A Prospective, Randomized Trial of Intravenous Prochlorperazine Versus Subcutaneous Sumatriptan in Acute Migraine Therapy in the Emergency DepartmentA Prospective, Randomized Trial of Intravenous Prochlorperazine Versus Subcutaneous Sumatriptan in Acute Migraine Therapy in the Emergency Department. Kostic MA et al. Ann Emerg Med 2010 Jul;56(1):1-6. Epub 2010 Jan 4.

My summary is as follows but obviously you should read this for yourself.
basically the IV compazine showed a "statistically singifcant" reduction in the visual analog pain scale at 80 minutes (this was a prospective double-blinded randomized controlled trial). There was no signficant difference in nausea or sedation levels. 8 patients became restless with compazine but non required anti-cholinergic therapy. No increase in side effects with sumatriptan.

So essentially compazine was more effective in relieving pain based on a visual analog scale.
A few cavets are this was a small study, the mean duraiton of HA was 2.7 days on average in the compazine group and was 1.7 in the sumatriptan. in terms of headache recurrence there was a non-statistically significant reduction in return of headache in the compazine group (although only 43% of these patients were contacted post-fu within 72hours versus 63% in the sumatriptan group.

In the end:
Both effective, maybe compazine more effective, maybe not but its definitely cheaper.

 

[Rendar5]

Thanks, that was the exact study that I based my opinion on. The thing about the study that really impressed me, (besides have a great method), if i remember correctly, was that IV compazine was near perfect in its relief of migraine, with the analog pain scale near 0 by the end of therapy on that branch. Fantastic summary by the way on the takeaway points and limitations of that study.

there is a prospective randomized trial comparing the two of these below:

A Prospective, Randomized Trial of Intravenous Prochlorperazine Versus Subcutaneous Sumatriptan in Acute Migraine Therapy in the Emergency DepartmentA Prospective, Randomized Trial of Intravenous Prochlorperazine Versus Subcutaneous Sumatriptan in Acute Migraine Therapy in the Emergency Department. Kostic MA et al. Ann Emerg Med 2010 Jul;56(1):1-6. Epub 2010 Jan 4.

My summary is as follows but obviously you should read this for yourself.
basically the IV compazine showed a "statistically singifcant" reduction in the visual analog pain scale at 80 minutes (this was a prospective double-blinded randomized controlled trial). There was no signficant difference in nausea or sedation levels. 8 patients became restless with compazine but non required anti-cholinergic therapy. No increase in side effects with sumatriptan.

So essentially compazine was more effective in relieving pain based on a visual analog scale.
A few cavets are this was a small study, the mean duraiton of HA was 2.7 days on average in the compazine group and was 1.7 in the sumatriptan. in terms of headache recurrence there was a non-statistically significant reduction in return of headache in the compazine group (although only 43% of these patients were contacted post-fu within 72hours versus 63% in the sumatriptan group.

In the end:
Both effective, maybe compazine more effective, maybe not but its definitely cheaper.

 

[xaelia]

Droperidol, wonder drug.

 

[fuegofrio17]

I have never used triptans as a first line agent in the ED because one of the major side effects is coronary artery vasoconstriction and coronary artery vasospasm.

It may be more prudent to give compazine or reglan to a patient you have no relationship with and may never see again. If the patient is under 40 and has no cardiac risk factors, I might consider it as a back up medication. But do you really want someone coming back with an MI later and claiming it was caused by the triptan you ordered?

 

[Rendar5]

Droperidol, wonder drug.

bu-bu-but, black box warning!!!!!😱

 

[tkim]

bu-bu-but, black box warning!!!!!😱

I want to use it so bad. But the need for an EKG and monitoring four hours post drug admin sounds bad.

 

[Pharmavixen]

There's the theoretical risk of serotonin syndrome from triptans + SSRIs. There hasn't been a problem when it's just one drug, but it's something to consider if the pt is on, say, citalopram 40 mg daily + trazodone 100 mg hs.

 

[deleted109597]

Eh, droperidol isn't that much better than compazine. Even though droperidol is safe there are too many bureaucracies to deal with at lots of places.

 

[toooldforthis]

Gimme good 'ol Phen/Dem any day.

BUT since the junkies moved in on the migraine sufferes turf and abused the drugs, we've been relegated to triptans (mostly).

Now i auto inject Sumitriptan Sub-Q, once the tachycardia dies down it's 2-4 hours sleep and resume daily functions...albeit at a slower pace.

 

[turkeyjerky]

anyone use zyprexa?

Olanzapine versus Droperidol for the Treatment of Primary Headache in the Emergency Department
Chandler H. Hill MD, James R. Miner MD, Marc L. Martel MD

"Both olanzapine and droperidol are effective treatments for primary headaches in the ED. No significant differences were found between the medications in terms of pain relief, antiemetic effect, or akathisia. Olanzapine may be used to treat primary headache and it is an effective alternative to droperidol"

 

[xaelia]

anyone use zyprexa?

I've tried it as second-line before. I wouldn't argue with anyone who wanted to try using it as first-line.

 

[roja]

In residency: Reglan plus NSAID plus benadryl (1 in 100 reaction decreased by benadryl, plus sleep good for migraine pts)

now: zofran plus nsaids.

I hate compazine (so many side effects and doesn't work any better than anything else)
its also more expensive in the hospital than zofran (want an interesting experience, start asking what different IV meds vs po cost in the hospital.)

I can't think of a single one only study that causes me to change my practice that dramatically.

As for droperidol, its an amazing drug. I treat black boxes with deeeeeeeeeeeeeep skepticism. Go read where it comes from. Look at the politics and finances behind these. (haldol is black boxed now.. still using it?)

I don't use triptans in the ED because there is almost no literature to support it for a migraine that has escalated. (its primarily an abortive and even that is iffy).

(you might be surprised at what you couldn't use if you stopped using all black boxed drugs: http://blackboxrx.com/)

 

[roja]

http://www.anesthesia-analgesia.org/content/95/4/789.short

 

[tkim]

As for droperidol, its an amazing drug. I treat black boxes with deeeeeeeeeeeeeep skepticism. Go read where it comes from. Look at the politics and finances behind these.

That being said, would you use droperidol?

 

[WilcoWorld]

I use droperidol. Mostly for nausea, but occasionally for migraines in patients reporting multiple allergies.

 

[KidDr]

In the peds ED I use Zofran + NSAID (usually Toradol) +/- Benadryl.

I have only used Triptans once, and it was on the advice of a neurologist who was treating the patient who ended up in the ED.

 

[Apollyon]

In residency: Reglan plus NSAID plus benadryl (1 in 100 reaction decreased by benadryl, plus sleep good for migraine pts)

now: zofran plus nsaids.

But Zofran (and other 5-HT3 antagonists) have no analgesic properties - only antiemetic. So, you're only going with the NSAID for pain relief, when it's a vascular thing going on. I mean, Reglan was found to work for headaches after use for "abdominal migraine", with the nausea and vomiting being found to be the analogue to pain in the head.

I mean, if it works for you, huzzah! It just makes me think of blowing the smoke out of a burning house, but not actually trying to put out the fire.

 

[xaelia]

I still remember, intern year, having some patient walk in with a sheaf of paper from her neurologist saying that she needed 8mg of Dilaudid for her chronic recurrent headaches.

...it worked.

I did not realize at the time how friggin' batshxt crazy that was.

 

[iridesingltrack]

That being said, would you use droperidol?

I use it about 2 times a week. I usually start with a small dose, 0.625mg IV which almost always cures n/v, after failing other antiemetics. Great drug.

I've never used drop for HA; generally, I have excellent success with compazine.

iride

 

[Rendar5]

But Zofran (and other 5-HT3 antagonists) have no analgesic properties - only antiemetic. So, you're only going with the NSAID for pain relief, when it's a vascular thing going on. I mean, Reglan was found to work for headaches after use for "abdominal migraine", with the nausea and vomiting being found to be the analogue to pain in the head.

I mean, if it works for you, huzzah! It just makes me think of blowing the smoke out of a burning house, but not actually trying to put out the fire.

Does compazine have analgesic properties? I've used compazine alone at times with fantastic effect on established migrainers (everyone else gets some variation on the h/a cocktail that we all use) without adding any analgesics into the bag, and had thought it was some other effect terminating the headache. Well I guess all we can say is what seems to work for one person may not be as effective for another.

 

[Apollyon]

Does compazine have analgesic properties? I've used compazine alone at times with fantastic effect on established migrainers (everyone else gets some variation on the h/a cocktail that we all use) without adding any analgesics into the bag, and had thought it was some other effect terminating the headache. Well I guess all we can say is what seems to work for one person may not be as effective for another.

Ipso facto, if it relieves pain, it's analgesic, by definition. So I'm not sure of your first question. If you mean, specifically, as "analgesic", NSAIDs and narcs, no, not the same. However, Compazine, Reglan, and, yes, Phenergan, relieve headache pain. That just has not been shown with Zofran and others of the class.

Again, the "abdominal migraine" - recall that you have as many neurons in your GI tract as in your brain. Reglan works for headache pain, along with nausea. Then again, would you think Benadryl? But Benadryl can be used as an anesthetic.

 

[emrox]

one nice thing about triptans, given no contraindications, is that they don't make someone sleepy and don't require an IV. i've had good luck with sumatriptan sq and even eletriptan for people who just want a pill.

i use droperidol frequently for headache and nausea and i agree with the wonder drug statements! compazine works well too. it's nice to have many non narcotic drugs in your arsenal for "headache" as different situations arise.

 

[streetdoc]

Droperidol is magical! I use it probably 5-6 times a shift for just about anything- usually 1.25mg with 25 of benadryl IV (2.5 mg if the pt is super crazy but my partners will use 5 mg). Of course it works well in n/v, but it fixes headache, abdominal cramps in tearful teenagers, back pain in pts that want the med that starts with a D, chest pain, tooth pain, "allergic" reaction, even fixes pts that you aren't real sure what their complaint is but after droperidol they say they feel better and are ready to go. honestly, I think the uses are endless. It should be in the water. I never used it in residency but it it didn't take me long to realize the amazing capabilities of this wonder drug. I think the black box warning is rediculous, but it keeps a lot of people from using it so at least there should never be a shortage for me and my droperidol crazy group.

streetdoc

 

[Tiger26]

Acad Emerg Med. 2001 Sep;8(9):873-9.
Droperidol vs. prochlorperazine for benign headaches in the emergency department.

Miner JR, Fish SJ, Smith SW, Biros MH.

Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, MN 55415, USA. [email protected]

At 60 minutes, 90.2% of the patients receiving droperidol and 68.6% of the patients receiving prochlorperazine had at least a 50% reduction in their VAS scores (p = 0.017). N

 

[DrMom]

I used droperidol a bunch when there was an IV compazine shortage a year or so ago and had excellent results like others have noted. I avoided it in those with a cardiac history (or would get a CYA EKG showing very normal QTc prior to administering). I never kept anyone for cardiac monitoring. Honestly not sure why I stopped using it.

I've never been in an ED where anyone was using triptans for HA.

 

[emrox]

Am J Emerg Med. 2007 Jan;25(1):60-4.
Sumatriptan for the treatment of undifferentiated primary headaches in the ED.
Miner JR, Smith SW, Moore J, Biros M.

Here's a study that used sumatriptan as first line for benign headache in the ED, regardless of migraine history. Around 60% of patients had at 50% reduction in their VAS Score.

Not overwhelming evidence for triptans, but interesting. I think they are worth considering in some cases.

 

[ORL10]

the only problem I see with the study that hennepin did on droperidol vs compazine is that there was no specific inclusion criteria for headache. It was up to the examiner to say if the headache was "benign".

In the compazine vs sumatriptan study there was a specific set of guidlines instituted using the IHS criteria. Additionally in this study if you look at 60 minutes all patients had >50% reduciton in VAS score which was not seen in the hennepin county study (68%). So why are they different?? is it because of the more rigorous inclusion criteria in the Annals study?

Anyways food for thought, our hospital doesn't use droperidol but for severe "migraines" compazine seems to be backed by the literature.

 

[deuist]

I've used triptans a few times for second-line therapy after reglan/toradol/benadryl haven't worked. It usually gets the job done for highly resistant headaches. I've never used droperidol, but the discussion on this forum sounds interesting. I will say that if you're concerned about QT prolongation, there are lots more drugs out there that can cause increased QTc, zofran included.

 

[gramcracker]

http://www.slrjournalclub.com/slrjournalclub.com/Migraine.html