Effectiveness and Safety of Propofol at Low Doses for Emergency Department Treatment of Migraine

IntroductionA migraine treatment protocol implemented in the emergency department of an urban hospital allowed us to evaluate the effectiveness of propofol compared to metoclopramide as well as the safety of the protocol. MethodsWe reviewed the health records of all patients aged 16 years and older treated with propofol for migraine between May 2014 and August 2017 at a teaching hospital in Quebec City (CHUL). The care protocol consisted of administering propofol (20 mg) every 5-10 minutes as needed (up to 6 doses), monitoring vital signs before and after each dose and continuous cardiac monitoring. The primary outcome measure was the mean reduction of pain following first-line therapy (propofol or metoclopramide). The secondary outcome measures were 1) adjusted relative risks of requiring rescue medication after first-line therapy; 2) incidence of the following side effects of propofol received as first or second-line therapy: low arterial pressure (< 90 systolic or < 65 mean), desaturation, excessive sedation, arrhythmia. The cohorts were paired for gender, age, triage priority, and month/year of ED visit. ResultsFiles of 34 patients given propofol and 58 given metoclopramide as first-line treatment were analyzed. Five metoclopramide-treated patients received propofol as rescue medication. Among propofol-treated patients, 29.4% experienced pain relief compared to 66% in the metoclopramide group (p < 0.001). Rescue medication was more frequent in first-line propofol patients (82.4% versus 37.9%, p < 0.001). In this group, four participants (10.3%) received intravenous fluid bolus for mean blood pressure below 60, but no persistent desaturation, bradycardia, excessive sedation, or arrhythmia was recorded. ConclusionThough less effective than metoclopramide, propofol at low doses may be an alternative to treat migraine in the ED. Monitoring of vital signs (especially blood pressure) would be prudent but continuous nursing is likely unnecessary.