Intramuscular Tramadol Vs. Diclofenac Sodium for The
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J Headache Pain (2005) 6:143–148 DOI 10.1007/s10194-005-0169-y ORIGINAL Zulfi Engindeniz Intramuscular tramadol vs. diclofenac sodium Celaleddin Demircan Necdet Karli for the treatment of acute migraine attacks Erol Armagan in emergency department: a prospective, Mehtap Bulut Tayfun Aydin randomised, double-blind study Mehmet Zarifoglu Received: 6 February 2005 Abstract The aim of this prospec- injection in future visits. Any Accepted in revised form: 15 April 2005 tive, randomised, double-blind study adverse events, whether related to Published online: 13 May 2005 was to evaluate the efficacy of intra- the drug or not, were also recorded. muscular (IM) tramadol 100 mg in Patients were followed up by tele- emergency department treatment of phone 48 h later to check for any acute migraine attack and to com- headache recurrence. Two-hour pain pare it with that of IM diclofenac response rate, which was the prima- sodium 75 mg. Forty patients who ry endpoint, was 80% for both tra- were admitted to our emergency madol and diclofenac groups. There department with acute migraine were no statistically significant dif- attack according to the International ferences among groups in terms of Z. Engindeniz (౧) • E. Armagan • M. Bulut Headache Society criteria were 48-h pain response, rescue treat- T. Aydin Department of Emergency Medicine, included in the study. Patients were ment, associated symptoms’ Uludag University Medical Faculty, randomised to receive either tra- response, headache recurrence and Acil Tip ABD Gorukle, madol 100 mg (n=20) or diclofenac adverse event rates. Fifteen (75%) Bursa 16059, Turkey sodium 75 mg (n=20) intramuscular- patients in the tramadol group and e-mail: [email protected] ly. Patients rated their pain on a 16 (80%) patients in the diclofenac Tel.: +90-224-442-8400 four-point verbal scale (0=none, group stated that they may prefer the Fax: +90-224-442-8400 1=mild, 2=moderate, 3=severe) at same agent for future admissions. In C. Demircan the beginning of the trial and at 30, selected patients, tramadol 100 mg Department of Internal Medicine, 60, 90 and 120 min. At each time IM may be an effective and reliable Uludag University Medical Faculty, interval, severity of associated alternative treatment choice in acute Bursa, Turkey symptoms were also questioned and migraine attacks. N. Karli • M. Zarifoglu recorded. Global evaluation of the Department of Neurology, drugs by patients and doctors were Key words Migraine treatment • Uludag University Medical Faculty, also recorded. Patients were also Tramadol • Diclofenac • Bursa, Turkey asked if they would prefer the same Randomised controlled trial symptoms, minimisation of length of stay and prevention Introduction of recurrence. Many treatment alternatives have been shown to be effective in the treatment of acute migraine Migraine headache is a common presenting complaint to attack including non-steroidal anti-inflammatory drugs the emergency department (ED). Aims of treatment (NSAID), antiemetics, phenothiazines, narcotics, ergot include rapid pain relief, improvement in associated alkaloids and triptans [1–9]. 144 Although it is not the recommended first-line therapy, they could clearly differentiate the type of headache. Patients in nearly half of migraine headaches emergency physi- who had taken analgesics or anti-migraine medication prior to cians in the USA prefer parenteral opioids [10]. Tramadol ED admission were included only if there was no response to is an opioid agent with central activity. Mechanism of its drug and if more than 6 h had passed between use of the drug and analgesic activity involves two components: low-affinity ED admission. Regular prophylactic migraine medications, other than antidepressants and antipsychotics (as they may interact binding to opioid receptors and inhibition of monoamine with central nervous system effects of tramadol), were allowed. reuptake [11]. Tramadol has a proven analgesic activity Patients were allowed to participate in the study only once. for many acute and chronic pain conditions [12–16]. After a detailed headache history, a general physical and Adverse effects, nausea in particular, are dose-dependent neurological examination was performed in all eligible patients and therefore considerably more likely to appear if the by the attending emergency physician. Diagnosis and eligibility loading dose is high. Other adverse effects are similar to for the study were then confirmed by a neurologist. Baseline those of other opioids but they appear to be less severe headache characteristics and presence or absence of associated [11]. Potential dependence, tolerance and abuse rates of symptoms (nausea, vomiting, photophobia and phonophobia) tramadol are also reported to be relatively low [17]. With were recorded. Severity of the headache was rated on a four- point verbal scale (0=none, 1=mild, 2=moderate, 3=severe) [19]. these features tramadol appears to have a potential role in After the collection of baseline data, patients were ran- the treatment of headaches. However, there is limited data domised to receive either tramadol 100 mg IM or diclofenac on its use in headache [10, 18] and we could not find any sodium 75 mg IM. Randomisation was achieved by computer- study on its use in acute migraine attack. based generation of random numbers. To assure blindness, tra- The aim of this study was to evaluate the efficacy of madol preparation, which was 2 ml, was completed to 3 ml with intramuscular (IM) tramadol 100 mg in ED treatment of normal saline solution to look identical to diclofenac sodium 75 acute migraine attack and to compare it with that of IM mg 3 ml preparation. Injections were prepared and applied by a diclofenac sodium 75 mg, an agent shown to be effective nurse who was not a part of the study. Neither the patient nor the physician was allowed to learn the contents of the injection until in treatment of acute migraine attacks [1–4], in a prospec- the end of the study period. tive, randomised and double-blind fashion. The primary After the injection, patients rated the severity of pain on the outcome measure of the study was 2-h pain response after four-point verbal scale at 30, 60, 90 and 120 min. At the end of the injection of the study drug. A sample size of 32 the study period (2 h), the presence or absence of associated patients was determined to achieve 80% power to detect symptoms was recorded. Patients were questioned about whether an effect size of 0.5 using a 1 degree of freedom Chi- or not they would prefer the same injection for future admissions. Square Test with a significance level (alpha) of 0.05. Any adverse events that could be related or not related to the drug were also recorded. Patients and doctors globally evaluated the drug on a 5-point verbal scale (0=very poor, 1=poor, 2=no opin- ion, 3=good, 4=very good). After these data were obtained the doctor and the patient were informed of the content of the injec- Methods tion. Then, the patients with a pain score of 2 (moderate) or 3 (severe) or with unbearable associated symptoms received rescue This prospective, randomised, double-blind trial was conducted treatment at the discretion of the emergency physician. Patients in a university hospital ED with an annual census of about were followed up by telephone 48 h after the ED admission and 26 000. The study was designed according to the second edition questioned about any headache recurrence, use of additional anal- of guidelines for controlled trials of drugs in migraine [19]. The gesics and any search for medical assistance. institutional review board and ethics committee approved the The primary outcome measure of the study was 2-h pain study (Decision number: 2003-24-03). Informed consent of all response and positive response was defined as pain score eligible patients was obtained before the study. The study was dropping from 3 or 2 to 1 or 0 within 2 h after the injection. performed in accordance with the ethical standards of the 1964 Secondary outcome measures were 2-h pain-free response, Declaration of Helsinki. 48-h pain response, 48-h pain-free response, response to associ- All patients between 18 and 65 years of age with acute ated symptoms, rescue treatment, recurrence and adverse event migraine attack according to the second edition of the rates. Two-hour pain-free response was defined as pain score International Headache Society (IHS) criteria for migraine with- dropping from 3 or 2 to 0 within 2 h. Positive 48-h pain out aura [20] were eligible. Patients with any known sensitivity response was defined as patients with a positive 2-h pain to either tramadol or diclofenac, patients taking excessive anal- response without rescue treatment and recurrence at 48-h fol- gesics (more than 10 days per month), patients using antidepres- low-up. Positive 48-h pain-free response was defined as sants and antipsychotics regularly within the last 3 months, patients with a positive 2-h pain-free response without rescue patients with history of epilepsy, alcohol or drug abuse, patients treatment and recurrence at 48-h follow-up. Response to associ- over 50 years of age with new onset migraine and pregnant or ated symptoms was accepted as positive if the symptom lactating patients were excluded from the study. improved or was completely relieved. Patients with other types of headache (e.g., tension-type All demographic, baseline, study and follow-up data were headache) together with migraine were included in the study if recorded on a standard study form by a resident or attending 145 physician. Data was then entered into SPSS 10.0 statistical soft- Results ware package (SPSS Inc. Chicago, IL) after the follow-up data were recorded. Forty-seven patients with acute migraine headache admit- The SPSS 10.0 statistical software package (SPSS Inc.