title: Randomized trial of IV valproate vs metoclopramide vs ketorolac for acute migraine.
abstract: OBJECTIVE
  We compared the efficacy of IV valproate with metoclopramide and with ketorolac in patients presenting to an emergency department (ED) with acute migraine.
  
  
  METHODS
  This was a double-blind comparative efficacy trial. Patients were randomized to 1,000 mg sodium valproate, 10 mg metoclopramide, or 30 mg ketorolac, each administered as an IV drip over 15 minutes. The primary outcome was improvement in headache by 1 hour, measured on a verbal 0 to 10 scale, at baseline and 60 minutes later. Important secondary outcomes included (1) need for rescue medication in the ED, and (2) sustained headache freedom.
  
  
  RESULTS
  Three hundred thirty patients were enrolled over 30 months beginning in October 2010. Baseline characteristics were comparable among the 3 arms. On the primary outcome, patients receiving IV valproate improved by a mean of 2.8 (95% confidence interval [CI]: 2.3, 3.3) on the 0 to 10 scale; those receiving IV metoclopramide improved by 4.7 (95% CI: 4.2, 5.2); and those receiving IV ketorolac improved by 3.9 (95% CI: 3.3, 4.5). On the secondary endpoints, 69% (95% CI: 60%, 78%) of patients receiving valproate required rescue medication, compared with 33% (95% CI: 24%, 42%) of metoclopramide patients and 52% (95% CI: 42%, 63%) of those assigned to ketorolac. Sustained headache freedom was achieved in 4% (95% CI: 0%, 7%) of those randomized to valproate, 11% (95% CI: 5%, 17%) of metoclopramide patients, and 16% (95% CI: 9%, 23%) receiving ketorolac. In the metoclopramide arm, 6% (95% CI: 3%, 12%) of patients reported feeling "very restless" after investigational medication administration.
  
  
  CONCLUSIONS
  Valproate was less efficacious than either metoclopramide or ketorolac. Metoclopramide demonstrated superiority to ketorolac on several endpoints.
  
  
  METHODS
  This study provides Class I evidence that in ED patients with acute migraine, IV valproate is inferior to metoclopramide or ketorolac in improving headache outcomes.
authors: From the Department of Emergency Medicine (B.W.F., A.Y., A.W., D.E., P.E.B., E.J.G.) and Pharmacy Department (C.S.), Montefiore Medical Center, and Medical College (L.G.), Albert Einstein College of Medicine, Bronx, NY.
authors: Benjamin W
authors: BW
authors: Friedman
authors: Leonid
authors: L
authors: Garber
authors: Andrew
authors: A
authors: Yoon
authors: Clemencia
authors: C
authors: Solorzano
authors: Andrew
authors: A
authors: Wollowitz
authors: David
authors: D
authors: Esses
authors: Polly E
authors: PE
authors: Bijur
authors: E John
authors: EJ
authors: Gallagher
mesh_terms: D000328:Adult; D000894:Anti-Inflammatory Agents, Non-Steroidal / Q000627:therapeutic use*; D000932:Antiemetics / Q000627:therapeutic use*; D018692:Antimanic Agents / Q000627:therapeutic use*; D004311:Double-Blind Method; D005260:Female; D006801:Humans; D020910:Ketorolac / Q000627:therapeutic use*; D008297:Male; D008787:Metoclopramide / Q000627:therapeutic use*; D008881:Migraine Disorders / Q000188:drug therapy*; D011446:Prospective Studies; D013997:Time Factors; D016896:Treatment Outcome; D014635:Valproic Acid / Q000627:therapeutic use*
chemical_list: D000894:Anti-Inflammatory Agents, Non-Steroidal; D000932:Antiemetics; D018692:Antimanic Agents; D014635:Valproic Acid; D008787:Metoclopramide; D020910:Ketorolac