Unconventional therapy

Oxygen Therapy

Cochrane review by Bennett et al in 2015 found data quality on this was poor to moderate, it concluded that there was some evidence that hyperbaric oxygen therapy was effective for the termination of acute migraine in an unselected population, and some evidence that normobaric oxygen therapy was similarly effective in cluster headache. Given the cost and poor availability of hyperbaric oxygen therapy, more research should be done on patients unresponsive to standard therapy. It concluded normobaric oxygen therapy is cheap, safe, and easy to apply, so will probably continue to be used despite the limited evidence in this review.⁹

IV Fluids

There has been two recent small single centre randomised control trial looking at the use of IV fluids. A pilot study assessing feasibility of a more large scale study by Jones et al in 2018 and last years I-Fibh trial by Zitek et al. In Jones et al randomized adult emergency department migraine headache patients to receive 1 L of normal saline solution during 1 hour (fluid group) or saline solution at 10 mL/hour for 1 hour (control group). I-FiBH and they were randomised to also receive either 20 mL/kg up to 1000 mL of normal saline or 5 mL of normal saline. All patients received intravenous prochlorperazine and diphenhydramine in both studies. Neither study showed a statistically treatment effect from fluid administration.^10,11

Propofol!?

A Metanalysis by Piatka et al found 9 studies looking at the use of Propofol in the management of Migraines including five case reports or series, one retrospective cohort study, and three randomized controlled trials, consisting of 290 patients. All studies in adults reported propofol to be an effective therapy for migraine, but the strength of these results was limited by dosing variations, small sample sizes, and limited generalizability. It conclude Propofol may be an effective rescue therapy for patients presenting to the ED for acute migraine, but its place in therapy based on the limited available evidence is unknown. The safety of propofol for migraine management in the ED has not been adequately examined… maybe will stick with the Aspirin for now.¹²

Intranasal Lignocaine

In a Metanalysis by Chi et al Six studies (n = 613) were found. Overall, the results revealed that the study population who was administered intranasal lidocaine had a lower pain intensity at 5 min (standardized mean difference (SMD) = -0.61; 95% CI = -1.04 to -0.19) and 15 min (SMD = -0.72; 95% CI = -1.14 to -0.19), had a higher success rate (RR = 3.55; 95% CI: 1.89 to 6.64) and a less frequent need for rescue medicine (RR = 0.51; 95% CI = 0.36 to 0.72) than the control group. Interestingly these beneficial effects were not observed when an antiemetic was administered. Furthermore, intranasal lidocaine use had no significant influence on the relapse rate (RR = 0.89; 95% CI = 0.51-1.56), regardless of the use of antiemetics. Using lidocaine caused local irritation in up to 49.4% of the patients in one report but did not cause major adverse events. The paper concludes Intranasal lidocaine can be considered a useful option for patients with an acute migraine. It yields a high success rate, a low pain intensity, an infrequent need for rescue medicine, and tolerable adverse events. The administration of antiemetics is an important confounding factor.¹³

Magnesium

A Metanalysis by Choi et al of double-blind, randomized controlled trials of intravenous magnesium for acute migraine in adults found five randomized controlled trials totalling 295 patients were eligible for the meta-analyses. The percentage of patients who experienced relief from headache 30 min following treatment was 7% lower in the magnesium groups compared with the controls [pooled risk difference=-0.07, 95% confidence interval (CI)=-0.23 to 0.09]. The percentage of patients who experienced side-effects or adverse events was greater in the magnesium groups compared with controls by 37% (pooled risk difference=0.370, 95% CI=0.06-0.68). Therefore failed to show any benefit of IV Magnesium.¹⁴

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