Migraine attacks can be successfully aborted with IV Metoclopramide

New research revealed that intravenous application of 10mg Metoclopramide was effective and successful in relieving migraine attacks with minimal side effects. Its efficacy was much higher than placebo and sumatriptan while lower than only granisetron. It also could completely relieve headaches and decrease the need for rescue medication much better than a placebo and valproate. The study was published in the journal BMC Neurology.

Often accompanied by nausea, vomiting, and extreme sensitivity to light, sound, and smell, migraine is a complex disorder of a neurovascular nature that is characterized by a severe throbbing, pulsatile pain that is localized to one side of the brain or the cerebral cortex or the brain stem and has a high propensity to recur. Metoclopramide, a central dopamine receptor blocker with peripheral muscarinic agonistic action [6] and anti-emetic properties, is frequently recommended as a reliable option for reducing discomfort and nausea and is thus recognized as an efficient single drug for the treatment of migraine in ED. Many drugs are prescribed in relieving acute migraine attacks, hence researchers conducted a systematic review and network meta-analysis to compare metoclopramide with other antimigraine drugs.

Databases like PubMed, Cochrane Library, Scopus, and Web of Science were searched till June 2022 for RCTs that compared metoclopramide alone with placebo or active drugs. The main outcomes were the mean change in headache score and complete headache relief. The secondary outcomes were the rescue medications need, side effects, nausea, and recurrence rate. Outcomes were qualitatively reviewed and the network meta-analyses (NMAs) were carried out which were done by the Frequentist method using the MetaInsight online software.

Key findings:

• Sixteen studies were included with a total of 1934 patients where 826 received metoclopramide, 302 received placebo, and 806 received other active drugs.
• Metoclopramide effectively reduced headaches even for 24 h.
• The intravenous route was the most chosen route and significant positive results were seen regarding headache outcomes. But the best route was not compared in the previous studies.
• Headache outcomes were effectively improved by both 10 and 20 mg doses of metoclopramide and 10 mg dose was the most frequently used dosage however, there was no direct comparison between both doses.
• In NMA of headache change after 30 min or 1 h, metoclopramide effect came after granisetron, ketorolac, chlorpromazine, and Dexketoprofen trometamol.
• Only granisetron’s effect was significantly higher than metoclopramide’s effect which was only significantly higher than placebo and sumatriptan.
• In headache-free symptoms, only prochlorperazine was non-significantly higher than metoclopramide which was higher than other medications and showed significantly higher effects only with a placebo.
• In rescue medication, metoclopramide’s effect was only non-significantly lower than prochlorperazine and chlorpromazine while its effect was higher than other drugs and showed higher significant effects only than placebo and valproate.
• In the recurrence rate, studies showed no significant difference between metoclopramide and other drugs.
• Metoclopramide significantly decreased nausea more than the placebo.
• Regarding side effects, metoclopramide showed a lower incidence of mild side effects than pethidine and chlorpromazine and showed a higher incidence of mild side effects than placebo, Dexamethasone, and Ketorolac.
• The reported extrapyramidal symptoms with Metoclopramide were dystonia or akathisia.

Thus, this is the first-ever study to perform a comprehensive review and network meta-analyses on the effect of metoclopramide in reducing acute migraine attacks compared to other anti-migraine drugs.

Further reading: Abdelmonem, H., Abdelhay, H.M., Abdelwadoud, G.T. et al. The efficacy and safety of metoclopramide in relieving acute migraine attacks compared with other anti-migraine drugs: a systematic review and network meta-analysis of randomized controlled trials. BMC Neurol 23, 221 (2023).https://doi.org/10.1186/s12883-023-03259-7