• 
• 

Three Part Question

In [adult patients attending the emergency department with acute migraine] is [metoclopramide better than prochlorperazine] at [relieving headache pain]?

Clinical Scenario

A 37-year-old woman presents at the emergency department with a left-sided headache. She has a past history positive for migraines and she describes the current episode as identical to her migraines. Your resident wants to prescribe prochlorperazine to treat her migraine, but you usually prescribe metoclopramide for patients with acute migraine. You wonder which of these dopamine antagonists is better for the treatment of a patient with acute migraine.

Search Strategy

No BestBETs or relevant critical appraisals were found on this topic at http://www.bestbets.org. No ongoing trials on this topic were registered at http://www.clinicaltrials.gov

Medline using NHS Evidence 24/04/2013:

[exp Migraine disorders/AND (exp metoclopramide/OR maxolon.ti,ab) AND exp prochlorperazine] six papers only the three listed were relevant and included.

Embase using NHS Evidence 24/04/2013: [exp Migraine/AND AND (exp metoclopramide/OR maxolon.ti,ab) AND exp prochlorperazine] Limit to (Clinical Queries Therapy best balance of sensitivity and specificity) and (Languages English); 81 results. No further relevant papers.

The Cochrane Library Issue 3 2013: MeSH descriptor: (Metoclopramide) explode all trees AND MeSH descriptor: (Prochlorperazine) explode all trees 26 records no new relevancies.

Search Outcome

3 papers as presented in the table

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Friedman et al 2008 USA	77 Adult patients with migraine receiving 20 mg metoclopramide IV (38) or 10 mg prochlorperazine IV (39) both accompanied by 25 mg diphenhydramine IV	Prospective double-blind RCT	Reduction in pain at 60 min (scale 0 to 10)	5.5 vs 5.2 (NSD)	Small number of patients Not the common use dose of metoclopramide Prophylaxic use of diphenhydramine
			Reduction in pain at 120 min (scale 0–10)	5.9 vs 6.4 (NSD)
Coppola et al 1995 USA	70 Adult patients with migraine receiving either 10 mg of metoclopramide IV (24) or 10 mg prochloperazine IV (22) or a placebo (24).	Prospective double-blind RCT	Pain score at 30 min (10 cm scale). Clinical success (defined as patient satisfaction and either a decrease of 50% or more in pain or an absolute pain of 2.5 cm or less)	3.9 vs 1.1 vs 6.1 48% vs 82% vs 29% (p<0.05)	Outcome measured at 30 minutes
Jones et al 1996 USA	86 Patients between 16 and 60 years old with migraine receiving 10 mg metoclopramide IM (n=28) vs 10 mg IM prochloperazine (28) vs placebo (29).	Prospective double-blind RCT	Reduction in median pain score at 60 min. Rescue narcotics required	34% vs 67% vs 16% (p<0.01) 79% vs 57% vs 86% (p=0.3)	Non consecutive patients

Comment(s)

The first two randomised controlled trials1 2 show a significantly better outcome with prochlorperazine 10 mg versus metoclopramide 10 mg The third study3 shows no significant difference between prochlorperazine and a higher dose of metoclopramide.

Editor Comment

IM, intramuscularly; IV, intravenously; RCT, randomised controlled trial.

Clinical Bottom Line

In adult patients presenting to the emergency department with acute migraine prochlorperazine 10 mg is better than metoclopramide 10 mg at relieving headache.

References

1. Friedman BW, Esses D, Solorzano C, et al. A randomized controlled trial of prochlorperazine versus metoclopramide for treatment of acute migraine Ann Emerg Med 2008;52:399–406.
2. Coppola M, Yealy DM, Leibold RA. Randomized, placebo-controlled evaluation of prochlorperazine versus metoclopramide for emergency department treatment of migraine headache. Ann Emerg Med 1995;26:541–6.
3. Jones J, Pack S, Chun E. Intramuscular prochlorperazine versus metoclopramide as single-agent therapy for the treatment of acute migraine headache. Am J Emerg Med 1996;14:262–4.