Three Part Question
In [patients presenting to the Emergency Department with acute migraine], does [intravenous propofol compared to standard therapy] [improve recovery or reduce recurrence] ?
A 34 years old female presents to your emergency department with acute migraine refractory to acetaminophen, NSAID and triptans. Your colleague talk to you about the use of propofol in migraine and you wonder if propofol would improve the chance of a complete resolution of her headache.
No previous Best BET was found on this topic. Medline on 4 February 2013, all years, via PubMed. Embase on 4 February 2013, all years. Cochrane library on 4 February 2013. http://clnicaltrials.gov on 4 February 2013: One trial found: ‘Low dose propofol for paediatric migraine’ not recruiting yet, to be completed January 2016.
Medline search: (propofol OR diprivan OR ‘propofol’(Mesh)) AND (migraine OR ‘migraine disorders’(Mesh)). Embase search : (exp Propofol/OR exp Diprivan/) AND (exp Migraine/OR migraine.mp.). Cochrane search: propofol AND migraine.
Medline search: 10 articles found, seven were relevant to the subject, three case reports and one review not showing original data. The three other studies are shown here.
Embase search: 23 articles found, eight were relevant to the subject, the same seven as in the Medline search and one review article not showing original data.
Cochrane search: No relevant article found.
|Author, date and country
||Study type (level of evidence)
|Soleimanpour et al|
|90 Patients (45 in each group) presenting to the ED with migraine as per International Headache Society criteria
Intervention: Propofol 10 mg every 5–10 min until pain relieved (max: 80 mg) 1 ml of lidocaine 2% added to every 10 ml of propofol Control: Dexamethasone 0.15 mg/kg (max: 16 mg). Exclusion: opioid, triptan, ergo 24 h before presentation ||Prospective randomized blinded clinical trial||Pain score at 10-20-30 minutes||Lower in propofol group for all time period (p<0,001) 10 min : 3,08 vs 5,13 20 min : 1,87 vs 3,73 30 min : 1,44 vs 3,06||No comparison with basic usual migraine medication (NSAID, anti-emetic). No prior use of anti-migraine medication. Short follow-up (45 min). Use of lidocaine with propofol
Data on % of complete resolution not shown
Side effect of mild sedation not otherwise described |
|Side effects||No differences in blood pressure and heart rate 44,4 % of mild sedation with propofol 2 cases of O2 desaturation to 89% with propofol|
|% Reduction in pain score from presentation to discharge||Greater in propofol group (80.1% vs 61.1%, p=0.02)|
|Length of stay in the ED||Similar in both groups (304 vs 308 min)|
|Sheridan et al|
|Paediatric patients (<18 years) in urban paediatric ED.
Intervention group: seven patients with diagnosis of migraine and use of propofol. Control: seven patients with diagnosis of migraine without use of propofol. Controls matched to cases by age, sex and use of daily prophylaxis. Exclusions: trauma, ventriculoperitoneal shunt, propofol given for other reasons than pain relief
Only paediatric study found ||Retrospective case-control study||% Reduction in pain score from presentation to discharge||Greater in propofol group (80,1 % vs 61,1%, p=0,02)||Very small number of patients
Decision to administer propofol based on clinical judgment
Probable selection bias
No strict criteria for enrolment
No predefined propofol administration protocol
Matched case-control design
|Length of stay in the emergency department||Similar in both group (304 vs 308 minutes)|
|Side effects||No apnea, hypoventilation, hypoxia or hypotension noted in either group|
|Krusz et al|
|77 Patients from an outpatient headache and pain clinic. Tension type or migraine headache not resolved by usual oral medication. No IV medication before propofol, 20–30 mg of propofol every 3–5 min until resolution of headache for a maximum of 1 h 1 ml of lidocaine, 2% added to 10 ml of propofol ||Prospective non-blinded observational study||Abolition of headache||82% (63/77)||Observational design
No comparison group
No strict criteria for enrolment
Use of lidocaine with propofol
No follow–up to monitor recurrence after treatment
No description of the population
Side effects no clearly described
|Relief of 50 to 90% of headache||18% (14/77)|
|Average dose of propofol||110mg|
Current evidence suggests that propofol is effective for treating migraine. Based on the current literature, we cannot conclude that it is superior to standard treatment for the resolution of migraine. No data on the rate of recurrence were found in the literature. Only one randomised controlled trial was found but the medication used in the control group is not a standard practice. The other studies were of poor quality. More well-designed studies comparing propofol to standard therapy are needed in paediatric and adult populations before widespread use of this modality. A clinical trial of propofol for paediatric migraine is registered at clinicaltrials.gov (NCT01604785) and will be completed in 2016 (Meckler, 2012). The few side effects observed with propofol do not seem to be clinically significant.
ED, emergency department; IV, intravenous; NSAID, non-steroidal anti-inflammatory drug.
Clinical Bottom Line
Propofol might be a safe and effective therapy in the treatment of migraine, but more well-designed trials are needed to compare with standard therapy before widespread use of this modality.
- Soleimanpour H, Ghafouri RR, Taheraghdam A, et al. Effectiveness of intravenous Dexamethasone versus Propofol for pain relief in the migraine headache: A prospective double blind randomized clinical trial BMC Neurology 2012;12:article number 114.
- Sheridan DC, Spiro DM, Nguyen T, et al. Low-dose propofol for the abortive treatment of pediatric migraine in the emergency department. Pediatr Emerg Care 2012;28:1293–6.
- Krusz JC, Scott V, Belanger J. Intravenous propofol: Unique effectiveness in treating intractable migraine. Headache 2000;40:224–30.
- Meckler G. Low dose propofol for pediatric migraine (NCT01604785). 2012 [cited 24 May 2013]. http://clinicaltrials.gov/ct2/show/NCT01604785?term=propofol+AND+migraine&rank=1