Department of Emergency Medicine, Faculty of Medicine & Dentistry, College of Health Sciences, University of Alberta, Edmonton, Alberta, Canada.
Evidera, Edmonton, Alberta, Canada.
Headache. 2024 Apr;64(4):424-447. doi: 10.1111/head.14704.
To assess the comparative effectiveness and safety of parenteral agents for pain reduction in patients with acute migraine.
Parenteral agents have been shown to be effective in treating acute migraine pain; however, the comparative effectiveness of different approaches is unclear.
Nine electronic databases and gray literature sources were searched to identify randomized clinical trials assessing parenteral agents to treat acute migraine pain in emergency settings. Two independent reviewers completed study screening, data extraction, and Cochrane risk-of-bias assessment, with differences being resolved by adjudication. The protocol of the review was registered with the International Prospective Register of Systematic Reviews (PROSPERO; CRD42018100096).
A total of 97 unique studies were included, with most studies reporting a high or unclear risk of bias. Monotherapy, as well as combination therapy, successfully reduced pain scores prior to discharge. They also increased the proportion of patients reporting pain relief and being pain free. Across the pain outcomes assessed, combination therapy was one of the higher ranked approaches and provided robust improvements in pain outcomes, including lowering pain scores (mean difference -3.36, 95% confidence interval [CI] -4.64 to -2.08) and increasing the proportion of patients reporting pain relief (risk ratio [RR] 2.83, 95% CI 1.74-4.61). Neuroleptics and metoclopramide also ranked high in terms of the proportion of patients reporting pain relief (neuroleptics RR 2.76, 95% CI 2.12-3.60; metoclopramide RR 2.58, 95% CI 1.90-3.49) and being pain free before emergency department discharge (neuroleptics RR 4.8, 95% CI 3.61-6.49; metoclopramide RR 4.1, 95% CI 3.02-5.44). Most parenteral agents were associated with increased adverse events, particularly combination therapy and neuroleptics.
Various parenteral agents were found to provide effective pain relief. Considering the consistent improvements across various outcomes, combination therapy, as well as monotherapy of either metoclopramide or neuroleptics are recommended as first-line options for managing acute migraine pain. There are risks of adverse events, especially akathisia, following treatment with these agents. We recommend that a shared decision-making model be considered to effectively identify the best treatment option based on the patient's needs.
评估治疗急性偏头痛患者疼痛的注射用药物的疗效和安全性。
已有研究表明，注射用药物治疗急性偏头痛疼痛有效，但不同方法的相对疗效尚不清楚。
检索了 9 个电子数据库和灰色文献来源，以确定评估在急诊环境中使用注射用药物治疗急性偏头痛疼痛的随机临床试验。两名独立的审查员完成了研究筛选、数据提取和 Cochrane 偏倚风险评估，分歧通过裁决解决。该综述的方案已在国际前瞻性系统评价注册库（PROSPERO；CRD42018100096）中注册。
共纳入了 97 项独特的研究，大多数研究报告存在高或不清楚的偏倚风险。单药治疗和联合治疗均能在出院前成功降低疼痛评分。它们还增加了报告疼痛缓解和无疼痛的患者比例。在评估的所有疼痛结局中，联合治疗是排名较高的方法之一，为疼痛结局提供了显著改善，包括降低疼痛评分（平均差值-3.36，95%置信区间[CI] -4.64 至 -2.08）和增加报告疼痛缓解的患者比例（风险比[RR] 2.83，95% CI 1.74-4.61）。神经安定药和胃复安在报告疼痛缓解的患者比例方面也排名较高（神经安定药 RR 2.76，95% CI 2.12-3.60；胃复安 RR 2.58，95% CI 1.90-3.49）和在急诊科出院前无疼痛（神经安定药 RR 4.8，95% CI 3.61-6.49；胃复安 RR 4.1，95% CI 3.02-5.44）。大多数注射用药物与不良反应增加相关，特别是联合治疗和神经安定药。
发现各种注射用药物均能有效缓解疼痛。考虑到各种结局的一致性改善，联合治疗以及作为一线治疗选择的甲氧氯普胺或神经安定药单药治疗均推荐用于治疗急性偏头痛疼痛。使用这些药物治疗后，有发生不良反应的风险，特别是静坐不能。我们建议考虑采用共享决策模型，根据患者的需求有效确定最佳治疗方案。
