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Three Part Question

In [adult ED patients with migraine by IHS criteria], does [intravenous magnesium] with or without [other headache agents] lead to [decrease in headache pain, resolution of headache or ED discharge]in a larger number of patients than those receiving other headache medications?

Clinical Scenario

A 34 year old female presents to the ED and states that she is having a "migraine" headache that has been present for 30 hours. She describes the headache has a frontal bilateral pressure associated with photophobia and nausea. She is afebrile and states that she has had headaches like this in the past but does not currently have any migraine medications at home and that the headache has not responded to OTC analgesics.

You decide to give the patient a dopaminergic agent such as prochlorperazine or metoclopramide but wonder if there is any other way to help her pain. Your ED pharmacist recently mentioned possibly adding 1g of magnesium to the "Headache Cocktail" order set in your electronic medical record. You wonder if the addition of magnesium to your normal treatment of migraine headaches is efficacious.

Search Strategy

Therapeutic Use of Magnesium in Migraine (Ovid PubMed)

Excluded migraine prophylaxis, theoretical, lab based, animal models
Included prospective, clinical comparison of magnesium vs. other agents or with other agents for the tx of acute migraine

magnesium.mp OR magnesium sulphate.mp OR MGSO4 (151991)
AND
migraine.mp (6181)

Search Outcome

31 total citations returned and five papers included in this review. The five paper included met criteria as human subject, clinically based and designed to test the use of magnesium in the treatment of migraine headache in the acute setting (i.e. not prophylaxis)

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Wilson et al 2000 USA	10 Pregnant Females with migraine by IHS criteria referred to neurology by ED and OB	case series	VAS change	8/10 Total Pain Relief, 2/10 No pain relief, p < 0.01	not randomized, no comparison group, small sample
Corbo et al 2001 USA	44 ED pts with migraine by IHS criteria	Randomized, double-blind, placebo controlled	VAS change at 0, 15, 30, 45 m		no significant difference in change
Bigal et al 2002 USA	60 ED pts with migraine by IHS criteria	randomized, double-blind, placebo controlled	VAS, side effects	no difference in migraine without aura group vs. placebo, statistically significant difference in migraine with aura group	mag alone, small sample, no CI, non-quantitative pain scale, no p-values or formal statistical testing
Cete et al. 2005 Turkey	113 ED pts with migraine by IHS criteria	randomized, double-blind, placebo controlled	VAS at 0, 15, 30; need for rescue meds, recurrance at 24h	no difference between groups, need for rescue med higher in placebo group	mag given alone
Demirkaya 2001 Turkey	30 ED pts with migraine by IHS criteria	Randomized, single-blind, placebo controlled	Qualitative pain assessment at 30m and 2h	all who received mag did have improvement, symptoms disappeared in 86.6% of mag group vs. 6.6% of placebo group	mag alone, small sample, no CI, non-quantitative pain scale, no p-values or formal statistical testing

Comment(s)

There are only a few RCTs comparing magnesium to other agents in the treatment of migraine. The majority of studies have focused on magnesium in migraine prophylaxis or the theoretical advantages of magnesium supplementation in headache sufferers. Physiologically, there is reason to believe that magnesium might be a useful adjunct to headache management. Magnesium plays both a role in serotonin modulation and vasoconstriction. In addition, it is implicated in blockade of NMDA-receptors. Many patients with a history of migraines have also been found to have chronically low magnesium levels. The data from these 5 studies is limited by sample size and design. The use of magnesium as a sole agent in headache relief is not common in our ED but it does come as part of a standard headache treatment order set. It would be useful to look at magnesium in the context of other headache treatments with a larger sample of patients.

Editor Comment

Mohammed Kamara to check from MRI site 21/10/2010

Clinical Bottom Line

There is no current evidence to support the routine use of IV magnesium in the management of International Headache Society defined migraine patients presenting to the ED. There is no evidence for the use of magnesium either as a sole agent in migraine treatment or as part of a combination of rescue medications.

References

1. Wilson, M C, O’Brien, W F. Intravenous Magnesium in the Treatment of Migraines during Pregnancy Obstetrics and Gynecology 2000; 182(1, Part 2):S154
2. Corbo J, Esses D, Bijur PE, Iannaccone R, Gallagher EJ. Randomized clinical trial of intravenous magnesium sulfate as an adjunctive medication for emergency department treatment of migraine headache. Ann Emerg Med 2001 Dec; 38(6):621-7.
3. Bigal ME, Bordini CA, Tepper SJ, Speciali JG. Intravenous magnesium sulphate in the acute treatment of migraine without aura and migraine with aura. A randomized, double-blind, placebo-controlled study. Cephalalgia 2002 Jun;22(5); 345-53.
4. Cete Y, Dora B, Ertan C, Ozdemir C, Oktay C. A randomized prospective placebo-controlled study of intravenous magnesium sulphate vs. metoclopramide in the management of acute migraine attacks in the Emergency Department. Cephalalgia 2005 Mar;25(3): 199-204
5. Demirkaya S, Vural O, Dora B, Topcuoglu MA. Efficacy of intravenous magnesium sulfate in the treatment of acute migraine attacks Headache 2001;41(2); 171-1777