ABSTRACT
BACKGROUND: It is not yet clear if corticosteroids are useful for the treatment of migraine. We determined the efficacy of 10 mg of IV dexamethasone as adjuvant therapy for patients presenting to an emergency department (ED) with acute migraine. METHODS: This was a randomized, double-blind, placebo-controlled multicenter trial. Subjects were randomized to dexamethasone 10 mg IV or placebo. As primary treatment for their migraine, all subjects received IV metoclopramide. Our primary hypotheses were the following: a greater percentage of patients with migraine who received dexamethasone would 1) achieve a headache-free state in the ED and maintain it for 24 hours and 2) have no headache-related functional impairment after ED discharge when compared to placebo. RESULTS: A total of 656 patients were approached for participation and 205 were randomized. The persistent pain-free outcome was achieved in 25% of those randomized to dexamethasone and 19% of placebo (p = 0.34). No functional impairment after ED discharge occurred in 67% of those randomized to dexamethasone and 59% of placebo (p = 0.20). In the subgroup of subjects with migraine lasting longer than 72 hours, 38% of those randomized to dexamethasone were persistently pain-free vs 13% of placebo (p = 0.06). Side effect profiles were similar, with the exception of acute medication reactions, which occurred more commonly in the dexamethasone group. CONCLUSION: A moderate dose of IV dexamethasone should not be administered routinely for the emergency department-based treatment of acute migraine, although it might be useful for patients with migraine lasting longer than 72 hours.
Subject(s)
Dexamethasone/administration & dosage , Emergency Medical Services/methods , Emergency Service, Hospital , Migraine Disorders/drug therapy , Acute Disease , Adult , Double-Blind Method , Female , Humans , Injections, Intravenous , Male , Middle Aged , Migraine Disorders/epidemiology , Migraine Disorders/pathologyABSTRACT
OBJECTIVE: To compare the efficacy of 20 mg of IV metoclopramide, given up to four times over 2 hours as needed for persistent headache, with 6 mg of subcutaneous sumatriptan for the emergency department treatment of migraine headaches. METHODS: This was a randomized, double-blind, clinical trial with two intervention arms. The primary endpoint was change in pain intensity as measured by an 11-point pain scale at 2 hours. Secondary endpoints included change in pain intensity at 24 hours and rates of pain-free headache relief at 2 and 24 hours. RESULTS: Two hundred two patients were screened, and 78 of 91 eligible patients were randomized. The two groups had comparable pain scores at baseline. By 2 hours, the change in pain intensity for the metoclopramide group was 7.2 compared with 6.3 for the sumatriptan group (95% CI for difference: -0.2 to 2.2). When compared at 24 hours, the metoclopramide group had improved by 6.1 compared with baseline and the sumatriptan group had improved by 5.0 (95% CI for difference: -0.6 to 2.8). At 2 hours, pain-free rates were 59% in the metoclopramide arm and 35% in the sumatriptan arm (95% CI for difference of 24%: 2 to 46%). The most common side effects at both time points were weakness, dizziness, and drowsiness, which were distributed evenly between the two groups. There were no reports of chest pain within the first 2 hours. The incidence of restlessness, stiffness, and abnormal movements was distributed equally between the two groups. CONCLUSIONS: When compared at 2 and 24 hours, aggressive (20 mg dosed up to four times) IV metoclopramide and 6 mg of subcutaneous sumatriptan relieved migraine headache pain comparably. Some secondary endpoints suggest that metoclopramide may be the preferable therapy for migraines presenting to the emergency department.
Subject(s)
Anti-Inflammatory Agents, Non-Steroidal/therapeutic use , Dopamine Antagonists/therapeutic use , Metoclopramide/therapeutic use , Migraine Disorders/drug therapy , Serotonin Receptor Agonists/therapeutic use , Sumatriptan/therapeutic use , Adult , Akathisia, Drug-Induced/etiology , Anti-Inflammatory Agents, Non-Steroidal/adverse effects , Diphenhydramine/administration & dosage , Dizziness/chemically induced , Dopamine Antagonists/administration & dosage , Dopamine Antagonists/adverse effects , Double-Blind Method , Drug Administration Schedule , Emergencies , Emergency Service, Hospital , Female , Flushing/chemically induced , Humans , Infusions, Intravenous , Injections, Subcutaneous , Male , Metoclopramide/administration & dosage , Metoclopramide/adverse effects , Pain Measurement , Serotonin Receptor Agonists/adverse effects , Sumatriptan/administration & dosage , Sumatriptan/adverse effects , Treatment OutcomeABSTRACT
One of the most difficult issues with which clergy must deal is that of theodicy, the reconciliation of a good God with evil in this world. The case of L.R. is that of a good thirty-nine-year-old man dying of cancer. This paper examines the role of the clergy in working with the dying patient, traditional responses to the questions of theodicy, and a proposal for an adequate contemporary solution to the issue of theodicy. One key factor in caring for the dying is the mutual spiritual growth of the dying patient and the clergy care giver.
