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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] ?

Clinical Scenario

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.

Search Strategy

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.

Search Outcome

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.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Soleimanpour et al 2012 Iran	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 2012 United States	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 2000 United States	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

Comment(s)

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.

Editor Comment

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.

References

1. 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.
2. 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.
3. Krusz JC, Scott V, Belanger J. Intravenous propofol: Unique effectiveness in treating intractable migraine. Headache 2000;40:224–30.
4. 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