High Dose Metoclopramide (20 mg IV over 15 min) Beats Subcut Sumitriptan (Imetrix) 6mg For Acute Headache

Metoclopramide 20 gm IV was VAS pain score  0.55/10 better on VAS than Sumitriptan injectable 6 mg. However, the later needed starting an IV and slow infusion over 15 minutes to avoid extrapyramidal oculogyric crisis (0.2% incidence with the 10 mg)

J Res Med Sci. 2013 Aug;18(8):695-8.
Metoclopramide versus sumatriptan for treatment of migraine headache: A randomized clinical trial.
Talabi S, Masoumi B, Azizkhani R, Esmailian M
http://www-ncbi-nlm-nih-gov.cyber.usask.ca/pmc/articles/PMC3872609/

  • 124 subjects
  • 20 gauge IV catheter – 20 mg metoclopramide (maybe made up to 20 mls D5W or saline) run in over 15 minutes. (I have an infusion pump which makes this relatively easy)
  • or Sumatriptan 6 mg subcut

Results:

metoclopramide

Comment – effectiveness can be improved by IV dexamethasone ? 4-8 mg IV (doesn’t mix with others) and ketoralac 60 mg/2ml IM. If get rare oculogyric crisis responds to Midazolam 2 mg IV:

Korean J Anesthesiol. 2012 Sep;63(3):274-6.
Extrapyramidal side effects after metoclopramide administration in a post-anesthesia care unit -A case report-.
Jo YY, Kim YB, Yang MR, Chang YJ.
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3460160/pdf/kjae-63-274.pdf

2 mg midazolam worked quickly but would need oximetry as would probably render semi-conscious. Would also require constant care/chaperoning..

I would probably give 10 mg initially over 15 minutes and see.  Once one had had metoclopramide, IV Dihydroergotamine could be supplemented as well in younger subjects. Beauty of Migraines dreugs is that none are sedating and patient can walk out after… goldengoosepaschers goldengoosepaschers

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