Acute Migraine Treatment in Emergency Settings: A systematic review and mixed treatment comparison.

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1 Acute Migraine Treatment in Emergency Settings: A systematic review and mixed treatment comparison. Brian H. Rowe, MD, MSc, CCFP(EM) Tier 1 Canada Research Chair in Evidence-based Emergency Medicine Professor, Department of Emergency Medicine University of Alberta

2 Collaborators Evidence-based Practice Centre, University of Alberta: Donna Dryden, PhD; Elizabeth Sumamo Schellenberg, MPH; Ben Vandermeer, MSc. ROW: Ian Colman, PhD; University of Ottawa, Ottawa, ON; Benjamin Freidman, MD; Montefiore Hospital, New York, NY, USA. Disclosure Investigator-controlled study funded by AHRQ; the research team does not have any affiliation with a commercial organization that may have a direct or indirect connection to the content of this presentation.

3 Introduction Acute migraine headache presentations to Emergency Departments (ED) occur frequently. Despite accepted treatment with anti-nauseants (e.g., metoclopramide), phenothiazines (e.g., prochlorperazine), NSAIDs (e.g., ketorolac), dihydro ergotamine (DHE), and narcotics, limited information exists regarding their comparative effectiveness. There is substantial practice variability among emergency clinicians with respect to treatment of acute migraines.

4 Objective To examine the comparative effectiveness of treatments for acute migraine H/A. To examine the comparative risks of adverse events (especially akathisia) from treatments for acute migraine H/A (MP 26). To examine the comparative effectiveness of treatments for prevent H/A relapse after discharge from the ED for acute migraine H/A.

5 Methods A priori systematic review protocol. Design: Restricted to randomized controlled trials. Inclusion: Studies involving patients treated for acute migraine H/A (population) with parenteral treatments (interventions) compared to placebo or other therapies (control), and reporting patientoriented outcomes (outcomes) were considered. Search: Ten databases up to January 2012 were searched using standardized approaches.

6 Methods Grey Literature: Conference proceedings, clinical trials registers, and reference lists were explored. Selection: Two reviewers independently selected studies, assessed methodological quality, and graded the evidence. Quality assessment: All included studies were assessed using the Cochrane Risk of Bias (RofB). Data Collection: One reviewer extracted, and a second verified data.

7 Methods Outcomes: Treatment efficacy measured by visual analogue scale, relapse, and other patient oriented outcomes. Statistics: Findings were qualitatively summarized using weighted mean differences (WMD) and 95% confidence intervals (CI). A meta-analysis and mixed treatment comparisons were conducted using odds ratios (OR) and 95% CIs.

8 Results Nine classes of drugs were investigated in 71 controlled trials. RofB was low for 28% of trials, unclear for 61%, and high for 11%.

9 Results Overall, most treatments are more effective than placebo. The comparative effectiveness of active treatments are infrequently studied. The relative benefits of the treatments can be compared using a network meta-analysis.

10 Network M-A Results

11 Knowledge translation activities Full Report (on line) Clinical Research Summary

12 Study Limitations Overall, there were limited head-to head comparisons and a small numbers of trials in each class. The systematic review only included RCTs, and many S/Es are only reported in observational studies. Publication bias: efforts to avoid this bias were made through a comprehensive search strategy. Selection Bias: efforts to avoid this bias were made by using multiple independent reviewers with accepted conflict resolution strategies.

13 Conclusions Overall, there are many effective treatments for acute migraine H/As in the ED setting. The most effective treatments are combination agents or mono-therapy with prochlorperazine Clinical practice guidelines should be developed to reflect these results. Future CE research should be conducted using standardized reporting.

14 Acknowledgments Funding: Systematic review: AHRQ. Dr. Rowe is supported as a Tier I Canada Research Chair in Evidence-based Emergency Medicine by CIHR (Ottawa, ON); RAs: Dion Pasichnyk, BSc; Christine Ha, BSc.

15 Thank you! Questions?

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