Aggressive IV metoclopramide treatment for migraine

"Aggressive" IV metoclopramide therapy for migraines is at least as effective as subcutaneous sumatriptan and may be a more option in emergency departments, according to a study in Neurology.The study compared the efficacy of 20mg intravenous (IV) metoclopramide, given up to four times over two hours, with 6mg of subcutaneous sumatriptan in the emergency department treatment of migraine headaches. To prevent dystonic reactions, diphenhydramine (25mg) was added to the first metoclopramide infusion and, if the patient required further treatment doses, the third metoclopramide infusion.The authors report a "clinically and statistically insignificant advantage" with metoclopramide for the primary outcome (a change in pain scores between 0 and 2 hours) and the secondary outcome (a change in pain scores between 0 and 24 hours). They also report that secondary outcomes (such as the need for rescue medication) suggested metoclopramide superiority over sumatriptan. There was no difference in the incidence of side effects between the groups, and chest pain was not reported within the first two hours.The authors describe the rationale for choosing the dosage regimens: "It has been established that a second dose of subcutaneous sumatriptan is no more effective than the first dose. The same cannot be said for metoclopramide. The dosing of metoclopramide chosen for this trial was greater than the one-time dose of 5 or 10 mg that is commonly administered in EDs. However, there have been no trials comparing different doses of metoclopramide... no evidence could be found to support what the investigators considered to be a very low dose of medication." The aggressive metoclopramide dosage regimen was chosen because of its demonstrated effectiveness in the authors' institution, the lack of adverse effects with higher doses in oncology practice, and because, "...the investigators felt strongly that it was important not to miss a potentially important clinical effect because of underdosing."Reference...