Abstract
Background
Headache is a common chief complaint in the emergency department (ED) setting.
Objectives
To compare analgesia with metoclopramide and diphenhydramine vs. intranasal ketamine
among ED patients with primary headache.
Methods
We enrolled a convenience sample of adults with a primary headache in a randomized,
single-blind, placebo-controlled trial. We randomized patients to either a control
arm (intravenous metoclopramide and diphenhydramine) or intranasal ketamine. The primary
outcome was change in pain 0–100 mm visual analog scale (VAS) score measured at study
start and 30 min post completion of initial medication administration. Secondary outcomes
included side effects, hospital admission, and return to care within 48–72 h.
Results
All 53 enrolled subjects completed the study, 26 of whom were allocated to the control
arm and 27 to intranasal ketamine. The mean change in pain VAS score at 30 min post
intervention was 22.2 mm in the control arm vs. 29.0 in the intranasal ketamine arm
(effect size difference 6.8 mm, 95% confidence interval −5.8–19.4). The incidence
of reported side effects was 65.4% in the control arm vs. 66.7% in the ketamine arm.
Three patients (11.5%) allocated to the control arm required admission for headache
pain control vs. 1 patient (3.7%) in the intranasal ketamine arm. Three (11.5%) additional
patients in the control arm returned to the ED within 48–72 h for headache pain vs.
none in the ketamine arm.
Conclusions
In this small randomized study, intranasal ketamine was not superior to standard therapy
among ED patients with primary headache syndromes.
Keywords
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Article info
Publication history
Accepted:
December 8,
2018
Received in revised form:
November 26,
2018
Received:
September 15,
2018
Footnotes
Disclaimer: The view(s) expressed herein are those of the author(s) and do not reflect the official policy or position of Brooke Army Medical Center, the U.S. Army Medical Department, the U.S. Army Office of the Surgeon General, the Department of the Army, the Department of Defense or the U.S. Government.
ClinicalTrials.gov Registration Number: NCT03081416.
Identification
Copyright
Published by Elsevier Inc.
ScienceDirect
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- THINK of Ketamine for HeadacheJournal of Emergency MedicineVol. 56Issue 4
- PreviewPrimary headache syndromes represent a significant burden of care in the emergency department (ED). Management challenges include refractory, recurrent, or prolonged symptoms (1,2). Standard treatment varies, but often entails administration of parenteral dopamine antagonists, nonsteroidal anti-inflammatory drugs (NSAIDs), fluids, corticosteroids, or diphenhydramine (1,2). Dopamine antagonists are an equivalent or preferred treatment to NSAIDs, and some consider them first-line treatment; however, dopamine antagonists can cause extrapyramidal effects, for example, restlessness or akathisia (5–46% of recipients) and diphenhydramine is often given to limit these effects (2,3).
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