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Three Part Question

In [patients with acute migraine], does including [IV fluid hydration with medication compared to treating with medication alone] result in [superior migraine pain relief]?

Clinical Scenario

Jennifer, a healthy 25-year- old medical student, presents to your emergency department (ED) during your afternoon shift with a severe headache that she has had for the past 8 hours. She has had nausea with vomiting for 6 hours. She has a long history of migraine headaches that keep her from her clinical duties for 1 or 2 days if untreated. After ruling out any cause for secondary headache, you decide to give 1 liter of intravenous (IV) saline along with IV metoclopramide. You consider if administration of IV fluid bolus might be associated with short-term or sustained outcomes

Search Strategy

Medline 1966-08/16 using OVID interface, Cochrane Library (2016), and Embase

[(exp migraine disorders/) AND (exp infusions, intravenous/ or exp intravenous fluids/ or exp rehydration/)]. Limit to English language.

Search Outcome

126 studies were identified; two studies addressed the clinical question.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Richer L, Craig W, Rowe B Oct 2014 Canada	Children and adolescents aged 5-17 presenting to the ED with migraine headache	RCT	Measuring response to IV fluid administration at 30 minutes, based on improvement of migraine pain severity	No clinically or statistically significant improvement in migraine pain severity based on use of the visual analog scale	Small sample size, pain was assessed after only 30 minutes, only partially blinded, and a relatively small volume of IV fluid was used (10 mL/kg).
			Assessing difference in pain relief caused by placebo effect by creating the expectation of receiving migraine medication in addition to IV fluids in the intervention group (group B)	No clinically or statistically significant difference between groups based on assessment of pain severity using the visual analog scale
Jerome E. B. Balbin, MD, Rebecca Nerenberg, MD, Alireza Baratloo, MD, Benjamin W. Friedman, MD, MS 2016 Dec United States	Adults up to 70 years of age presenting with acute migraine or probable migraine	Post hoc analysis of 4 ED-based randomized comparative efficacy studies	Compared groups’ improvement in pain score from before treatment to 1 hour after treatment (0-10 pain scale)	There was an average difference in headache improvement score between groups of 0.6 on the 0-10 pain scale, in favor of patients having slightly greater headache relief when fluids were not administered. This was not considered statistically significant however	Post hoc study, lack of randomization, selection bias, co-interventions (such as metoclopramide) were applied differently to the treatment and control groups; and the volume of fluids infused was not standardized
			Compared rate of sustained headache relief (being headache free while in the ED and 24 hours after ED discharge without needing more medication)	There was a 4% greater rate of sustained headache relief in the metoclopramide only group, but this was not considered statistically significant

Comment(s)

Migraine is often accompanied by nausea and vomiting, thus suggesting that intravenous fluids (IVF) may be of benefit. In fact, current practice of many emergency medicine physicians in the United States and Canada is to include an IVF bolus in their treatment plan (1,2). While adequate hydration might improve patient malaise, and orthostatic symptoms, and prevent some of the adverse cardiovascular effects seen with many migraine therapies, there is no current research data to support a direct analgesic effect of IVF. A randomized trial is needed to address this question definitively.

Clinical Bottom Line

There is no evidence to support the routine use of IVF in the treatment of acute migraine headache in the emergency department.

References

1. Lawrence Richer, MD, MSc; William Craig, MD, MSc; Brian Rowe, MD, MSc Randomized Controlled Trial of Treatment Expectation and Intravenous Fluid in Pediatric Migraine Headache Oct 2014, 54(9):1496-505
2. Balbin JE, Nerenberg R, Baratloo A, Friedman BW Intravenous fluids for migraine: a post hoc analysis of clinical trial data American Journal of Emergency Medicine 2016; 34:713-716.