title: A randomized trial of intravenous ketorolac versus intravenous metoclopramide plus diphenhydramine for tension-type and all nonmigraine, noncluster recurrent headaches.
abstract: OBJECTIVE
  We compare metoclopramide 20 mg intravenously, combined with diphenhydramine 25 mg intravenously, with ketorolac 30 mg intravenously in adults with tension-type headache and all nonmigraine, noncluster recurrent headaches.
  
  
  METHODS
  In this emergency department (ED)-based randomized, double-blind study, we enrolled adults with nonmigraine, noncluster recurrent headaches. Patients with tension-type headache were a subgroup of special interest. Our primary outcome was a comparison of the improvement in pain score between baseline and 1 hour later, assessed on a 0 to 10 verbal scale. We defined a between-group difference of 2.0 as the minimum clinically significant difference. Secondary endpoints included need for rescue medication in the ED, achieving headache freedom in the ED and sustaining it for 24 hours, and patient's desire to receive the same medication again.
  
  
  RESULTS
  We included 120 patients in the analysis. The metoclopramide/diphenhydramine arm improved by a median of 5 (interquartile range 3, 7) scale units, whereas the ketorolac arm improved by a median of 3 (IQR 2, 6) (95% confidence interval [CI] for difference 0 to 3). Metoclopramide+diphenhydramine was superior to ketorolac for all 3 secondary outcomes: the number needed to treat for not requiring ED rescue medication was 3 (95% CI 2 to 6); for sustained headache freedom, 6 (95% CI 3 to 20); and for wish to receive the same medication again, 7 (95% CI 4 to 65). Tension-type headache subgroup results were similar.
  
  
  CONCLUSIONS
  For adults who presented to an ED with tension-type headache or with nonmigraine, noncluster recurrent headache, intravenous metoclopramide+diphenhydramine provided more headache relief than intravenous ketorolac.
authors.affiliation: Department of Emergency Medicine, Albert Einstein College of Medicine, Bronx, NY. Electronic address: bwfriedmanmd@gmail.com.
authors.forename: Benjamin W
authors.initials: BW
authors.lastname: Friedman
authors.forename: Victoria
authors.initials: V
authors.lastname: Adewunmi
authors.forename: Caron
authors.initials: C
authors.lastname: Campbell
authors.forename: Clemencia
authors.initials: C
authors.lastname: Solorzano
authors.forename: David
authors.initials: D
authors.lastname: Esses
authors.forename: Polly E
authors.initials: PE
authors.lastname: Bijur
authors.forename: E John
authors.initials: EJ
authors.lastname: Gallagher
mesh_terms: D000328:Adult; D000894:Anti-Inflammatory Agents, Non-Steroidal / Q000008:administration & dosage / Q000627:therapeutic use*; D004155:Diphenhydramine / Q000008:administration & dosage / Q000627:therapeutic use*; D018492:Dopamine Antagonists / Q000008:administration & dosage / Q000627:therapeutic use*; D004311:Double-Blind Method; D004359:Drug Therapy, Combination; D005260:Female; D006261:Headache / Q000188:drug therapy*; D006801:Humans; D006993:Hypnotics and Sedatives / Q000008:administration & dosage / Q000627:therapeutic use*; D007262:Infusions, Intravenous; D020910:Ketorolac / Q000008:administration & dosage / Q000627:therapeutic use*; D008297:Male; D008787:Metoclopramide / Q000008:administration & dosage / Q000627:therapeutic use*; D008875:Middle Aged; D059408:Pain Management / Q000379:methods; D010147:Pain Measurement; D012008:Recurrence; D018781:Tension-Type Headache / Q000188:drug therapy*
chemical_list: D000894:Anti-Inflammatory Agents, Non-Steroidal; D018492:Dopamine Antagonists; D006993:Hypnotics and Sedatives; D004155:Diphenhydramine; D008787:Metoclopramide; D020910:Ketorolac