Propofol for the treatment of migraines in the ED might be on the horizon. This will possibly be a new practice in emergency medicine, although it has been known for some time. Propofol, when given at procedural sedation doses, seems to miraculously terminate migraines refractory to usual treatment. Patients awake with minimal to no headache and may be discharged from the ED much quicker than traditional treatment with possibly less side effects. The proposed mechanism of action is described in below papers, but in short, propofol seems to “reboot” the brain and terminate the migraine.
What is the evidence?
Headache, the Journal of Head and Face Pain
It all started with a Headache paper 1 in the late 1990s at a headache clinic using propofol for procedural sedation during epidural blocks.
- 77 patients with headache severity ≥7/10 on VAS failing outpatient oral regimens
- Non-blinded 20-30 mg of IVP propofol every 3-5 minutes until symptom resolution not to exceed 1 hour
- Average reduction in headache severity = 95.4% at 30 minutes
- 82% had total abolition of migraines and associated symptoms
- 18% had a VAS-pain decrease of 50-90%
- 3 of 77 patients had return of headache the following day
- Average dose of propofol 110 mg (~1-1.5 mg/kg for average size adult)
- No adverse events
Then in 2012, Soleimanpour et al 2 published a prospective randomized double-blind trial conducted in Iran.
- 90 adult ED patients presenting with a migraine
- Propofol 10 mg IVP every 5-10 minutes (maximum of 80 mg) versus dexamethasone 0.15 mg/kg (max 16 mg) IVP
- Propofol performed statistically better as measured by VAS pain reduction at 5, 10, 20, 30, and 45 minute marks
- Propofol group adverse events: 2 patients desat to 89% resolving with O2 administration
Pediatric Emergency Care
Don’t forget that kids get migraines too! A 2012 retrospective case-control review in Pediatric Emergency Care 3 from a pediatric ED studied kids with migraines who received propofol compared to standard treatment.
- 7 pediatric patients with migraines receiving sub-anesthetic doses of propofol were compared to those with usual abortive therapy (NSAIDs + prochloroperazine + diphenhydramine)
- Average of 1.71 mg/kg of propofol total given as 10-50 mg IVP doses
- Propofol was significantly better at decreasing VAS pain (80% vs 60%)
- No difference in length-of-stay after medications
- No difference in re-visits after 24 hours
- No adverse events
There is more data on the horizon. Study NCT01604785 will be recruiting 160 kids to evaluate propofol versus standard treatment for pediatric migraines.
If you do decide to use propofol for migraines, here are some recommendations:
- Consider for patients failing usual rescue treatments
- Follow your ED’s protocol for procedural sedation
- Administer propofol as 10-20 mg IVP every 3-4 minutes up to 1 mg/kg
- Aim to have a lightly sedated patient – the goal is not for the EtCO2 to disappear
- Consider one-dose of dexamethasone 10 mg IV/PO prior to discharge to prevent recurrence 4,5
We at UCSF are also doing a multi-center retrospective study of propofol in the ED. If you’ve given or seen propofol in your ED for migraines, we’d love to have you participate.
There might be some benefit to the milky goodness of propofol for intractable migraines in the ED, but adequate trials are currently lacking. Let me know your feedback!