Numerous studies have shown that narcotics are not needed for treating migraines.  They are often inferior and almost never found to be better.  Of course, they are also highly addictive, as many emergency doctors readily know if they use narcotics.  Those given narcotics for migraines in the emergency room seem to keep coming back more and more often.

In 8 studies, non-narcotics did better in 3, as well with fewer side-effects in 2, equally well in 2 and in only one small study did the narcotic do better.  Clearly, non-narcotics win.

Meperidine: Dihydroergotamine as Good as Meperidine with Fewer Side-Effects: In a DB study in the emergency rooms of 11 hospitals of 171 adults with migraine headaches, 1 mg dihydroergotamine did as well as 1.5 mg/kg meperidine by intramuscular injection. Both groups received the anti-nauseant hydroxyzine. Reduction of headache pain as measured on a 100-mm visual analog scale was 41 mm (54% reduction) for DHE vs. 45 mm (56% reduction) for MEP at 60 minutes after treatment, virtually identical. CNS side-effects were less common with DHE: 24% vs. 38%, especially dizziness. Double-blind, multicenter trial to compare the efficacy of intramuscular dihydroergotamine plus hydroxyzine versus intramuscular meperidine plus hydroxyzine for the emergency department treatment of acute migraine headache. Carleton SC, et al. University Hospital of Cincinnati. . Ann Emerg Med 1998 Aug;32(2):129-38.

Meperidine: Metoclopramide Better than Demerol for Severe Headaches in ER: In a DB PC study of 336 patients in the emergency room with acute severe migraine or tension headaches for no more than 7 days in a row, metoclopramide produced more effective analgesia than pethidine in both types of headaches. Prospective, randomised, double blind, controlled comparison of metoclopramide and pethidine in the emergency treatment of acute primary vascular and tension type headache episodes. Cicek M et al. Dokuz Eylul University Medical School, Izmir, Turkey. Emerg Med J 2004 May;21(3):323-6. Studies of intravenous MTP reported benefit over placebo and in one a success rate of 67%.

Meperidine: Ketorolac Better Than Meperidine Which Was No Better Than Placebo for Headaches in ER: Intramuscular ketorolac 60 mg, meperidine 50 mg plus promethazine 25 mg, and normal saline were compared in acute exacerbations of tension headaches in 41 adults. All three groups showed a significant improvement that persisted for the 6 hours of evaluation. Ketorolac treatment was significantly better than placebo at 0.5 and 1 hour by the Visual Analog Scale (VAS) and Pain Rating Index, and better than meperidine at 2 hours (by the VAS). Meperidine and placebo did not differ at any time point. Harden RN, Rogers D, Fink K, et al. Controlled trial of ketorolac in tension-type headache. Neurology 1998;50:507–9.

Meperidine: Dihydroergotamine as Good as Meperidine with Fewer Side-Effects: In a DB study of 27 adults with acute migraine headaches, 75 mg meperidine with 25 mg promethazine IM did no better than .5 mg dihydroergotamine with 10 mg metoclopramide IV, but side effects were significantly greater in the meperidine with promethazine. The dihydroergotamine with metoclopramide regimen is effective, and has minimal side effects. Comparison of dihydroergotamine with metoclopramide versus meperidine with promethazine in the treatment of acute migraine. Scherl ER, et al. University of Kentucky. Headache 1995 May;35(5):256-9.

Meperidine: Dihydroergotamine Combination Superior to Meperidine Combination: In a DB study of 28 patients with acute headaches, dihydroergotamine 1 mg and metoclopramide 10mg IV and a placebo injection IM, did much better than meperidine 75 mg and hydroxyzine 75 mg IM and a placebo injection IV for improvement in pain scale score (P = 0.006). The number of patients having a mild or no headache with dihydroergotamine was (13/14) vs. (3/14) for meperidine. (P < 0.001) The authors conclude, " The combination of dihydroergotamine and metoclopramide IV should replace the standard IM narcotic and anti-emetic as the parenteral treatment of choice for severe migraine headache." Current emergency treatment of severe migraine headaches. Klapper JA, et al. St. Joseph Hospital, Denver, CO. Headache 1993 Nov-Dec;33(10):560-2.

Meperidine: Ketorolac IM as Good as Meperidine with Hydroxyzine IM: In a DB study of 47 adult migraine patients, IM ketorolac 60 mg did as well as meperidine 100 mg with hydroxyzine 50 mg with almost identical pain relief scores. Ketorolac versus meperidine and hydroxyzine in the treatment of acute migraine headache: a randomized, prospective, double-blind trial. Duarte C, et al. University of Illinois, Peoria. Ann Emerg Med 1992 Sep;21(9):1116-21. Ed: This is not really a fair comparaison, since hydroxyzine by itself has been found to help pain.  A true comparaison would have been to have both ketorolac and meperidine be combined with hydroxyzine. 

Meperidine IM Did Better than Ketorolac in Small Study: In a small DB study of 31 adults with acute migraine headaches, ketorolac 30 mg IM did not do as well as meperidine 75 mg 75 mg. At one hour, ketorolac was significantly less effective than meperidine in reducing headache pain (P = .02) and in improving clinical disability (P = .01). Ketorolac also was less effective at reducing nausea, photophobia, and the need for additional medication (P< .05). A randomized, double-blind, comparative study of the efficacy of ketorolac tromethamine versus meperidine in the treatment of severe migraine. Larkin GL, et al. West Virginia University. Ann Emerg Med 1992 Aug;21(8):919-24. Ed: Small studies such as this can often end up a chance results which are not true findings.  Since ketorolac has done as well and often better than narcotics including meperidine in other studies, it is likely that this study is a fluke result that doesn't reflect reality.

Meperidine: Methotrimeprazine Did as Well as Meperidine: In a DB study of 74 patients with severe migraines, IM methotrimeprazine, a non-narcotic, nonaddicting phenothiazine did just as well as a combination of meperidine and dimenhydrinate. There were no statistical differences in pain intensity one hour after treatment, change in pain intensity, or pain relief as measured on a visual-analog scale; need for additional analgesia; persistence of nausea or vomiting; adverse effects; or follow-up status, except for prolonged drowsiness, in the group receiving methotrimeprazine. The authors conclude, " Methotrimeprazine may be considered an effective, nonaddicting, IM alternative to narcotics for the management of this problem." Methotrimeprazine versus meperidine and dimenhydrinate in the treatment of severe migraine: a randomized, controlled trial. Stiell IG, et al. University of Ottawa, Canada. Ann Emerg Med 1991 Nov;20(11):1201-5.

Propoxyphene: Migraines: Ergotamine Equal to Dextropropoxyphene at Preventing: In a DB crossover study of 25 patients with 525 acute migraines, ergotamine was equally effective as preventing migraines compared to dextropropoxyphene and both were better than aspirin. Patient preference did not differ between ergotamine and propoxyphene. Hakkarainen H, et al. J Clin Pharmacol 1980;20:590-5.

Thomas E. Radecki, M.D., J.D.

modern-psychiatry.com