Subcutaneous Sumatriptan for Treatment of Acute Migraine in Patients Admitted to the Emergency Department: A Multicenter Study

doi:10.1016/S0196-0644(95)70259-8

Annals of Emergency Medicine

Volume 25, Issue 4, April 1995, Pages 464-469

Presented at the Society for Academic Emergency Medicine Annual Meeting in San Francisco, California, May 1993.

https://doi.org/10.1016/S0196-0644(95)70259-8 Get rights and content

Abstract

See related editorial, "Sumatriptan: A Clinical Standard?"

Study objective: To assess the efficacy of SC sumatriptan injection versus placebo in the treatment of acute migraine in ED patients and that of open-label 100 mg sumatriptan PO tablets for recurrent migraine.

Design: Randomized, double-blind, placebo-controlled, multicenter trial. Setting: Twelve EDs in the United States. Participants: Adult patients presenting to the ED from September 1992 through April 1993 with a diagnosis of migraine as determined by International Headache Society criteria. Patientswere randomized to receive 6 mg sumatriptan SC or placebo.Patients were monitored for improvement in headache severity using a four-point scale and for time to meaningful relief using a stopwatch. The time to discharge from the ED was recorded. An open-label 100 mg sumatriptan PO tablet was given to all patients on discharge from the ED for use at home if the headache recurred within 24 hours. Results: One hundred thirty-six patients were enrolled. Seventy-five percent of patients treated with sumatriptan achieved meaningful relief compared with 35% treated with placebo (P<.001). The median time to meaningful relief was 34 minutes in the group that received sumatriptan. Seventy percent of patients in the sumatriptan group versus 35% in the placebo group reported mild or no pain at discharge (P<.001). Migraine-associated symptoms such as nausea, photophobia, and phonophobia were significantly reduced in the sumatriptan group (P<.005). The median time to discharge from the ED was shorter for the sumatriptan group than for the placebo group (60 versus 96 minutes, respectively; P =.001). At baseline, 15% of patients in the sumatriptan group and 19% of patients in the placebo group reported mild or no clinical disability. At the time of discharge, patients with mild or no disability increased to 75% in the sumatriptan group compared with 44% in the placebo group (P =.001). Fifty-seven of 92 patients (62%) with mild or no pain at discharge took open-label oral sumatriptan for headache recurrence, and 37 (65%) experienced meaningful relief within 2 hours. Median time to meaningful relief after oral sumatriptan was 65 minutes. Conclusion: Sumatriptan (6 mg SC) is effective in treating acute migraine in the ED. Oral sumatriptan (100 mg) is effective in treating headache recurrence within 24 hours. [Akpunonu BE, Mutgi AB, Federman DJ, Volinsky FG, Brickman K, Davis RL, Gilbert C, Asgharnejad M: Subcutaneous sumatriptan for treatment of acute migraine in patients admitted to the emergency department: A multicenter study. Ann Emerg Med April 1995;25:464-469.]

Section snippets

INTRODUCTION

An estimated 1.6% to 2.5% of emergency department patients present with the chief complaint of headache. Migraine is the ultimate diagnosis in 4% to 22% of these patients.1, 2 Management of migraineurs in the ED requires the use of an effective drug that has an acceptable adverse-event profile and minimum or no abuse potential.

Medications commonly used in the EDs to treat migraine include narcotics, combination analgesics, tranquilizers, barbiturates, nonsteroidal anti-inflammatory drugs, ergot

MATERIALS AND METHODS

T his multicenter, randomized, double-blind, placebo-controlled study involved 12 US EDs. Patients were randomized in blocks of six with a 2:1 ratio of sumatriptan to placebo. Patients were enrolled from September 1992 through April 1993.

Patients 18 years of age or older who met the International Headache Society classification for migraine without aura (common) or for migraine with aura (classic) were eligible for participation.²⁴ It was required that patients had a migraine headache history

RESULTS

One hundred thirty-six patients completed the study. Demographic characteristics and baseline migraine types are given in Table 1.Placebo and sumatriptan groups were comparable with respect to age, sex, ethnic origin, baseline blood pressure, and migraine type. The median duration of headache before the ED visit was 16 hours for the placebo group and 13 hours for the sumatriptan group (P =NS). Associated symptoms present at baseline (nausea, vomiting, photophobia, phonophobia) and the degree of

DISCUSSION

More than 11 million people in the United States have migraine headaches with moderate-to-severe disability.²⁵ Extrapolated health care and labor loss ascribed to migraines range from $5.6 to $17.2 billion.²⁶ Of patients presenting to EDs, 1.6% to 2% have headache as their chief complaint, with 4% to 22% complaining of migraine.1, 2 Headaches are associated with significant disability related to pain, nausea, vomiting, photophobia, phonophobia, and dehydration, including lost time from work.

CONCLUSION

Subcutaneous sumatriptan (6 mg) is effective in treating patients who present to the ED with an acute migraine and is convenient to administer. Compared with placebo, patients who received subcutaneous sumatriptan spent less time in the ED. Oral sumatriptan appears to be effective in relieving recurring migraine attacks. Further controlled clinical trials are warranted to confirm the efficacy of sumatriptan.

Acknowledgements

This study was supported by a grant from Glaxo Pharmaceuticals, Incorporated. The authors acknowledge Maureen Gilmore for her word processing assistance in preparing the manuscript.

The authors acknowledge the following investigators and members of the US Sumatriptan Research Group who contributed to the conception, conduct, and analysis of data and preparation of the manuscript.

Clinical Investigators: B Akpunonu, MD; A Mutgi, MD; D Federman, MD; C Brickman, MD; M Diamond, MD; F Frietag, DO; G

References (27)

MJ Leicht
Non-traumatic headache in the emergency department
Ann Emerg Med
(1980)
WT Beaver
Combination analgesics
Am J Med
(1984)
GL Larkin et al.
A randomized double-blind comparative study of the efficacy of ketorolac tromethamine versus meperidine in the treatment of severe migraine
Ann Emerg Med
(1992)
KV Iserson
Parenteral chlorpromazine treatment of migraine
Ann Emerg Med
(1983)
R Bell et al.
A comparative trial of three agents in the treatment of acute migraine headache
Ann Emerg Med
(1990)
IG Stiell et al.
Methotrimeprazine versus meperidine and dimenhydrinate in the treatment of severe migraine: A randomized, controlled trial
Ann Emerg Med
(1991)
DS Tek et al.
A prospective, double-blind study of metoclopramide hydrochloride for the control of migraine in the emergency department
Ann Emerg Med
(1990)
V Dhopesh et al.
A retrospective assessment of emergency department patients with complaint of headache
Headache
(1979)
ML Diamond
Emergency department treatment of the headache patient
Headache Q Curr Treatment Res
(1992)
RL Dickman et al.
The management of non-traumatic headache in a university hospital emergency room
Headache
(1979)

JA Klapper et al.

Current emergency treatment of severe migraine headaches

Headache

(1993)

RE Ryan

A study of Midrin® in the symptomatic relief of migraine headache

Headache

(1974)

A Pradalier et al.

Treatment review: Non-steroid anti-inflammatory drugs in the treatment and long-term prevention of migraine attacks

Headache

(1988)

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The advent of the triptans revolutionized acute migraine treatment. The older migraine-specific drugs, the ergot alkaloids (ergotamine and dihydroergotamine), also relieve migraine attacks through agonism at the 5-HT_1B and 5-HT_1D receptors, but the triptans have much greater specificity for these receptors. Unlike the ergot alkaloids, the triptans do not activate many other receptor types, and therefore are much better tolerated. This reduction in side effects greatly enhanced their clinical utility as it allowed a far greater proportion of patients to take a full therapeutic dose. As a result, the clinical use of ergotamine is minimal today, although dihydroergotamine still has a significant clinical role. There is extensive evidence that the seven triptans available today, sumatriptan, zolmitriptan, rizatriptan, eletriptan, naratriptan, almotriptan, and frovatriptan, are effective in the acute treatment of migraine. Available formulations include oral tablets, orally dissolving tablets, subcutaneous injections, nasal sprays, and in some countries, rectal suppositories. For optimal benefit, therapy needs to be individualized for a given patient both regarding the triptan chosen and the formulation. This chapter discusses the ergot alkaloids and the triptans, including mechanism of action, evidence for efficacy, clinical use, and adverse effects.
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Headache is a common presenting condition for patients seen in the pediatric emergency department (ED). Intranasal (IN) sumatriptan is a well-tolerated and safe abortive treatment for migraine headache, but it is infrequently administered in pediatric EDs. In this study we characterize an ED migraine pathway that uses IN sumatriptan as a first-line treatment.
We performed retrospective chart analysis from a single center, reviewing a cohort of patients treated on an ED migraine pathway between October 2016 and February 2020. We reviewed patient demographics, clinical characteristics, treatment patterns, change in pain scores, sumatriptan prescriptions at discharge, length of stay (LOS), ED charges, and unexpected return visits.
A total of 558 patients (aged six to 21 years, 66% female) were included in this study. Overall, the median pretreatment pain score was 7 (interquartile range [IQR]: 5 to 8) and the median post-treatment pain score was 2 (IQR: 0 to 4). Forty-eight percent of patients received IN sumatriptan in the ED, and 36% of those who received sumatriptan were prescribed oral sumatriptan at discharge. When intravenous (IV) access was obtained for headache management, this was associated with a significantly longer LOS and higher ED charges.
IN sumatriptan shows promise as a feasible and potentially effective first-line treatment for pediatric migraine in the ED that could reduce the need for IV therapies, shorten LOS, and lower ED charges. Further research is needed to determine the efficacy of IN sumatriptan relative to other common first-line therapies used to treat pediatric migraine in the ED.
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Serotonin receptor agonists such as sumatriptan (triptans) are hypothesized to prevent pain signal propagation by inhibiting calcitonin gene-related peptide (CGRP) release.92 Triptans are effective in treating migraines and cluster headaches.93,94 Administration of 6 mg subcutaneous sumatriptan may be used to treat acute migraines in the emergency setting93 with repeat delivery of 6 mg after 1 h if symptoms persist (max 12 mg per day).12
Pain is the root cause for the overwhelming majority of emergency department (ED) visits worldwide. However, pain is often undertreated due to inappropriate analgesic dosing and ineffective utilization of available analgesics. It is essential for emergency providers to understand the analgesic armamentarium at their disposal and how it can be used safely and effectively to treat pain of every proportion within the emergency setting. A ‘balanced analgesia’ regimen may be used to treat pain while reducing the overall pharmacologic side effect profile of the combined analgesics. Channels-Enzymes-Receptors Targeted Analgesia (CERTA) is a multimodal analgesic strategy incorporating balanced analgesia by shifting from a system-based to a mechanistic-based approach to pain management that targets the physiologic pathways involved in pain signaling transmission. Targeting individual pain pathways allows for a variety of reduced-dose pharmacologic options – both opioid and non-opioid – to be used in a stepwise progression of analgesic strength as pain advances up the severity scale. By developing a familiarity with the various analgesic options at their disposal, emergency providers may formulate safe, effective, balanced analgesic combinations unique to each emergency pain presentation.
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Subcutaneous sumatriptan 2.5 mg is effective in the outpatient and ED settings, with a number needed to treat of 2.5 when compared with placebo, with a median time to pain relief of 34 min (9–13,47). Other routes include 10 to 20 mg intranasally or 100 mg orally (10,11,46–48). However, this medication is associated with significant adverse effects, including flushing, chest pain, shortness of breath, and even worsening of headache, with a number needed to harm of 4 (47).
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This review evaluates the treatment of benign, primary headaches in the ED, with recommendations provided based on the literature.
Headaches are a major cause of disability in the United States and a common condition managed in the ED. The primary objectives of emergency evaluation of these patients include evaluation for a life-threatening, secondary cause of headache, with treatment of primary headaches. Close evaluation for a secondary cause of headache include consideration of red flags and focused neurologic examination. The diagnosis of primary headaches is clinical. Literature has evaluated medication efficacy in headache treatment, with antidopaminergic medications demonstrating high rates of efficacy when used in combination with nonsteroidal inflammatory drugs or acetaminophen. Dexamethasone can be used for the reduction of headache recurrence. If dehydration is present, intravenous fluids should be provided. Diphenhydramine is not recommended for analgesia but may reduce akathisia associated with prochlorperazine. Ketamine, propofol, and nerve blocks demonstrate promise. Triptan agents are also efficacious, provided absence of contraindications. Most patients are appropriate for discharge with pain improvement.
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^☆: From the Departments of Internal Medicine^* and Emergency Medicine^‡, Medical College of Ohio, Toledo; and Glaxo, Incorporated, Research Institute, North Carolina.^§

^☆☆: Address for reprints: Basil E Akpunonu, MD, Department of Internal Medicine and Emergency Department, Medical College of Ohio, 3000 Arlington Avenue, Toledo, Ohio 43699-0008, Fax 419-382-0354

^★: Reprint no. 47/1/63469

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Subcutaneous Sumatriptan for Treatment of Acute Migraine in Patients Admitted to the Emergency Department: A Multicenter Study☆,☆☆,★

Abstract

Section snippets

INTRODUCTION

MATERIALS AND METHODS

RESULTS

DISCUSSION

CONCLUSION

Acknowledgements

Ann Emerg Med

Am J Med

Ann Emerg Med

Ann Emerg Med

Ann Emerg Med

Ann Emerg Med

Ann Emerg Med

A retrospective assessment of emergency department patients with complaint of headache

Headache

Emergency department treatment of the headache patient

Headache Q Curr Treatment Res

The management of non-traumatic headache in a university hospital emergency room

Headache

Current emergency treatment of severe migraine headaches

Headache

A study of Midrin® in the symptomatic relief of migraine headache

Headache

Treatment review: Non-steroid anti-inflammatory drugs in the treatment and long-term prevention of migraine attacks

Headache