Photo Credit: Kobus Louw

The following is a summary of “Effectiveness and Safety of Pharmacologic Therapies for Migraine in the Emergency Department: A Systematic Review and Bayesian Network Meta-analysis,” published in the December 2024 issue of Emergency Medicine by DeSouza et al. 

Researchers conducted a retrospective study with a Bayesian network meta-analysis to compare the relative effectiveness and safety of pharmacologic therapies in adults with migraine presenting to the emergency department (ED).  

They searched MEDLINE, Embase, and Web of Science from inception to February 9, 2024. Randomized controlled trials, which enrolled adults with migraines in the ED and compared pharmacologic therapies or placebos, were included. The outcomes were adequate pain relief at 2 hours, pain intensity change at 1 hour, rescue drug use at 2 hours, and significant adverse reactions. Data were extracted per PRISMA-network meta-analysis and appraised with Cochrane Risk of Bias 2 (RoB 2). Bayesian network meta-analysis was used for odds ratios with 95% credible intervals (dichotomous outcomes), and frequentist network meta-analysis calculated mean differences with 95% CI (continuous outcomes). Confidence was assessed using Confidence in Network Meta-analysis and Surface Under the Cumulative Ranking Curve (SUCRA) ranked agents.  

The results showed the chlorpromazine intravenous (IV)/intramuscular (IM) [SUCRA] = 87.3% was most effective for “adequate pain relief at 2 hours” (24 trials; n = 2,361). Metoclopramide IV-ibuprofen IV (SUCRA = 94.6%) ranked highest for “need for rescue drug” (avoiding rescue drug) at 2 hours (27 trials; n = 2,942). Dexamethasone IV (SUCRA = 79.5%) was the most favorable for “significant adverse reaction” (minimizing adverse reactions) (22 trials; n = 2,450). The network for change in pain intensity showed statistically significant incoherence at the overall level. Confidence in network meta-analysis estimates varied, with evidence-primarily rated as “low” or “very low,” limiting the reliability of probabilistic conclusions.  

Investigators concluded that chlorpromazine IV/IM was among the most effective for adequate pain relief, while ibuprofen IV, valproate IV, and possibly ketorolac IV/IM were among the least effective, with insufficient certainty regarding the relative safety of the therapies. 

Source: annemergmed.com/article/S0196-0644(24)01197-1/abstract