IS METOCLOPRAMIDE EFFECTIVE FOR TREATING MIGRAINES IN THE ED?
Metoclopramide (Reglan) is a dopamine and serotonin antagonist that is used off-label to treat migraine headaches in the emergency department (ED). Because metoclopramide is an antiemetic, it makes sense that this drug can be effective for nausea and vomiting associated with certain types of headaches. Not quite as obvious is whether metoclopramide can be used to treat migraine pain.
A meta-analysis published in 2004 analyzed 13 randomized controlled trials evaluating parenteral metoclopramide for the treatment of migraine.1 Although the methods of each study varied considerably and the quality of some studies was poor, data revealed that intravenous (IV) metoclopramide monotherapy was superior to placebo for reduction of headache pain. The number needed to treat for one patient to show a benefit with IV metoclopramide was 4. The reviewers concluded that metoclopramide should be considered a primary agent for treatment of acute migraine in EDs. In another study, aggressive IV metoclopramide (when given with diphenhydramine) provided pain relief equal to subcutaneous sumatriptan (Imitrex).2
The tricky part is determining which patients with migraines will benefit from metoclopramide therapy. Most treatment guidelines recommend either primary therapy or adjunctive therapy with an antiemetic in patients presenting with migraine associated with nausea or vomiting. However, when metoclopramide should be used as monotherapy in migraine sufferers in the ED is less clear. Determining what patients have responded to in the past is always a good idea.
On a final note, metoclopramide has a black box warning for irreversible tardive dyskinesia. Although the risk is greater with long-term dosing (more than 12 weeks) and total cumulative dose, caution should be exercised in
certain patient populations. It appears
that older patients, women, and patients with diabetes are at greatest risk of this irreversible adverse effect. Metoclopramide is also not recommended in children with migraines and patients with Parkinson disease because of the risk of acute dystonic reactions and extrapyramidal symptoms.
WHAT SHOULD BE KEPT IN
AN OUTDOOR FIRST AID KIT?
Most commercial emergency first aid kits contain a bare minimum of supplies that should be expanded based on each individual member of the group. Basic medications include NSAIDs, acetaminophen, aspirin, diphenhydramine, topical antibiotics, and topical corticosteroids. Supplies such as sterile gauze, antiseptic wipes, adhesive bandages or tape, and tweezers may also be included in the kit.
Specializing a first aid kit is essential. Pay attention to type of outdoor activity and individual members of the party. For a person with diabetes, glucose tablets or a glucagon injector kit may be life-saving items. For people at risk for anaphylactic reactions to food or insects (bees), an epinephrine auto-injection kit is also vital (usually given in conjunction with diphenhydramine). H2 receptor antagonists such as ranitidine (Zantac) may also be used for anaphylaxis, but the evidence supporting their use is conflicting. Combining H1 and H2 receptor antagonists may be slightly more beneficial for pruritus and urticaria than an H1 blocker alone. Albuterol should always be on hand when a person in the party suffers from asthma. A small supply of personal prescription medications should be included if needed (for example, nitroglycerin).
Other items that may prove useful in a first aid kit include antidiarrheals (loperamide), antacids, oral rehydration salts, sunscreen, and topical products to treat blisters. If a first aid kit is planned for a water activity, meclizine to treat motion sickness may also be a good idea. Some health care professionals carry suture kits and basic CPR equipment. Keep an eye on expiration dates, and replace products when needed. JAAPA
Larissa DeDea, PharmD, BCPS, PA-C, completed a pharmacy practice residency at Gallup Indian Medical Center, Gallup, New Mexico, and has worked on the Navajo Reservation as a pharmacist for the Public Health Service. In addition to being board certified in pharmacotherapy, she is a recent graduate of the Yale University PA Program.
REFERENCES
1. Colman I, Brown MD, Innes GD, et al. Parenteral metoclopramide for acute migraine: meta-analysis of randomised controlled trials. BMJ. 2004;329(7429):1369-1373.
2. Friedman BW, Corbo J, Lipton RB, et al. A trial of metoclopramide vs sumatriptan for the emergency department treatment of migraines. Neurology. 2005;64(3):463-468.