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Low-dose Propofol for the Treatment of Severe Refractory Migraine Headache in the Emergency Department

The safety and scientific validity of this study is the responsibility of the study sponsor and investigators. Listing a study does not mean it has been evaluated by the U.S. Federal Government. Read our disclaimer for details.
 
ClinicalTrials.gov Identifier: NCT02492295
Recruitment Status : Terminated (Due to logistic reason)
First Posted : July 8, 2015
Results First Posted : March 19, 2020
Last Update Posted : March 19, 2020
Sponsor:
Information provided by (Responsible Party):
Albert Einstein Healthcare Network

Brief Summary:

Migraine headache is a frequent Emergency Department complaint. While first-line Emergency Department treatment for this condition is well-established, optimal second-line treatment options are not well-defined. First line Emergency Department treatments include Non-Steroidal Anti-Inflammatory Drugs (NSAIDs), dopamine antagonists. Second line treatments that have been proposed include triptans, steroids, antiepileptics, benzodiazepines, magnesium and narcotics, but none have shown reliable Emergency Department efficacy (less than 50% in most studies). In the past ten years there have been several case series published on using low, sub-anesthetic doses of propofol for the treatment of refractory migraine. These case series have reported very impressive efficacy rates, especially in comparison to the published efficacy rates of other second-line treatments. Personal experience using this treatment modality has also yielded impressive clinical results. Most of the published series, however, have not been conducted in the Emergency Department.

The Investigators propose to conduct a prospective, observational trial of low-dose propofol for the treatment of refractory migraine in the Emergency Department. Propofol is a frequently-used Emergency Department sedative, with a good safety profile when administered by experienced Emergency Medicine practitioners using appropriate monitoring. The primary outcome measurement will be reduction of pain after treatment, with secondary outcome measures related to the safety of treatment and continuation of pain relief after leaving the Emergency Department. Although the protocol will involve the use of low-dose propofol with the aim of achieving light-to-moderate sedation only, all patients will care for and monitor at a level appropriate for deep procedural sedation.


Condition or disease Intervention/treatment Phase
Migraine Headache Drug: Propofol Not Applicable

Detailed Description:

This is a prospective, open-label, observational trial to assess basic efficacy and safety in the Emergency Department treatment environment.

Emergency Department patients at Einstein Medical Center Philadelphia, with migraine type headache (International Headache Classification), who continue to have severe (6/10 or greater) pain one hour after receiving adequate first-line treatment with a dopamine antagonist (prochlorperazine or metoclopramide) and an NSAID (ketorolac or ibuprofen) will be approached for possible inclusion. Patients who meet all inclusion/exclusion criteria will be given informed consent, including consent for procedural sedation. Patients who decline to participate will continue to have their headache treated by the ED team as per usual practice.

After enrollment, patients will be set up for procedural sedation per standard Emergency Department protocol. This includes a well-running peripheral IV; continuous monitoring with telemetry, pulse oximetry, capnography and automated blood pressure checks; continuous bedside monitoring by both an Emergency Department nurse and an Emergency Department attending or senior resident (with immediate attending availability); and airway management tools including suction, oxygen, and Bag valve mask ventilation at bedside, with advanced airway management tools (intubation equipment, etc) immediately available. After time-out, propofol administration will begin. The study drug will be administered only by those properly trained to do so and will be administered in compliance with healthcare licensure requirements. Propofol will be administered as a 0.5mg/kg (at a concentration of 10mg/mL, rounded to the nearest 0.5mL) initial bolus, followed by repeat 0.25mg/kg boluses (same rounding) every three to five minutes as needed to maintain Richmond Agitation Sedation Scale (RASS) target -2 ("light sedation - awakens to voice <10 seconds") to RASS target of -3 ("moderate sedation - movement or eye opening without eye contact") for 15 minutes. No more than 1.5mg/kg of propofol will be administered over this time period. After the sedation session is complete, patients will be allowed to wake up and will be monitored in the ED for at least another hour prior to discharge.

If a patient experiences any adverse safety event that in the determination of the treating provider make it unsafe to continue giving propofol, the protocol will be terminated immediately.

Numeric pain score (0-10) will be obtained prior to medication administration, at 30 minutes and at 60 minutes after the final dose of medication. Patients will also be questioned about associated migraine symptoms (nausea/vomiting/photophobia/phonophobia) and their resolution. Patients will receive follow-up phone calls at 24 hours to assess pain score, need for additional medications and whether they would opt for the same treatment again in the event of another severe headache. Patient charts will subsequently be reviewed to determine if they had any further ED visits within 72 hours after propofol administration.

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Study Type : Interventional  (Clinical Trial)
Actual Enrollment : 12 participants
Allocation: N/A
Intervention Model: Single Group Assignment
Masking: None (Open Label)
Primary Purpose: Treatment
Official Title: Low-dose Propofol for the Treatment of Severe Refractory Migraine Headache in the Emergency Department
Actual Study Start Date : August 2014
Actual Primary Completion Date : January 1, 2016
Actual Study Completion Date : January 1, 2016

Resource links provided by the National Library of Medicine

MedlinePlus Genetics related topics: Migraine
MedlinePlus related topics: Headache Migraine
Drug Information available for: Propofol

Arm Intervention/treatment
Experimental: Propofol
Propofol is administered intravenously as a 0.5mg/kg (at a concentration of 10mg/mL, rounded to the nearest 0.5mL) initial bolus, followed by repeat 0.25mg/kg boluses (same rounding) every three to five minutes as needed to maintain RASS target -2 ("light sedation - awakens to voice <10 seconds") to RASS target of -3 ("moderate sedation - movement or eye opening without eye contact") for 15 minutes.
Drug: Propofol
Propofol will be administered as a 0.5mg/kg (at a concentration of 10mg/mL, rounded to the nearest 0.5mL) initial bolus, followed by repeat 0.25mg/kg boluses (same rounding) every three to five minutes as needed to maintain RASS target -2 ("light sedation - awakens to voice <10 seconds") to RASS target of -3 ("moderate sedation - movement or eye opening without eye contact") for 15 minutes. No more than 1.5mg/kg of propofol will be administered over this time period. After the sedation session is complete, patients will be allowed to wake up and will be monitored in the ED for at least another hour prior to discharge.
Other Names:
  • Diprivan
  • Propoven




Primary Outcome Measures :
  1. Pain Assessed by Numeric Pain Score [ Time Frame: 60 minutes ]
    Numeric pain score 1 hour after completion of propofol administration.


Secondary Outcome Measures :
  1. Pain Assessed by Numeric Pain Score [ Time Frame: 24 hours ]
    Numeric Pain Score

  2. Pain Assessed by Numeric Pain Score [ Time Frame: 30 minutes ]
    Numeric pain score 30 minutes after completion of propofol administration.

  3. Additional Rescue Medications Used [ Time Frame: 24 hours ]
    Need for other pain relief medications for migraine after use of propofol

  4. Patient Willingness to Use Propofol Again in Case of Refractory Migraine as Assessed by Patient Questionaire [ Time Frame: 24 hours ]
    Assessed by questionnaire read to patient over phone (yes/no answer)

  5. Emergency Room Re-admissions [ Time Frame: 72 hours ]
    May reflect treatment failure or occurrence of adverse events/reactions-determined by Response is Yes or No

  6. Hypoxia: SpO2 of <88% [ Time Frame: 60 minutes ]
    SpO2 of <88% up to 60 minutes after propofol administration or until patient is fully alert.

  7. Hypotension: Blood Pressure of < 100/60 [ Time Frame: 60 minutes ]
    Blood pressure of < 100/60 up to 60 minutes after propofol administration or until patient is fully alert.

  8. Number of Patients Needing Basic Airway Repositioning Maneuver During Sedation [ Time Frame: 60 minutes ]
    Assessed by questionaire filled out by research associate during drug administration. This Will report the number of patients who required a basic airway repositioning maneuver (jaw thrust/head tilt) during the course of the sedation.

  9. Number of Patients Needing Advanced Airway Intervention (Beyond Simple Repositioning)(Composite) [ Time Frame: 60 minutes ]
    Assessed by questionnaire filled out by research associate during drug administration. Will report the composite number of patients (if any) who required an advanced airway maneuver, specifically insertion of a nasal-pharyngeal airway (NPA) or oro-pharyngeal airway (OPA), use of a bag-valve-mask (BVM), endotracheal intubation (ETT) or surgical airway. While only a composite number will be reported as a secondary outcome, we will give details in the text of any such interventions. We *do not* anticipate that any such interventions will be required during the study, and thus are not going to pre-specify the above interventions as separate individual outcome measures, but will instead report a composite number, with relevant details in the text.

  10. Number of Patients With Allergic (Anaphylactic-spectrum) Reactions That May be Attributed to Propofol Use (Composite) [ Time Frame: 60 minutes ]
    Assessed by questionnaire filled out by research associate during and after drug administration. The number of patients (if any) with an anaphylactic-spectrum response will be reported as a composite number, and in the text we will provide a specific description of the reaction(s), which might include itching, urticaria, airway swelling, or wheezing/stridor. Please note that we *do not* anticipate any such reactions to propofol, and thus are not going to pre-specificy these reactions individually as separate outcome measures, but will instead report a composite, with relevant details in the text.

  11. Hypercarbia: End Tidal Carbon Dioxide (ETCO2) of >50 mm Hg [ Time Frame: 60 minutes ]
    ETCO2 of >50 mm Hg up to 60 minutes after propofol administration or until patient is fully alert.



Information from the National Library of Medicine

Choosing to participate in a study is an important personal decision. Talk with your doctor and family members or friends about deciding to join a study. To learn more about this study, you or your doctor may contact the study research staff using the contacts provided below. For general information, Learn About Clinical Studies.


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Ages Eligible for Study:   18 Years to 65 Years   (Adult, Older Adult)
Sexes Eligible for Study:   All
Accepts Healthy Volunteers:   No
Criteria

Inclusion Criteria:

  • Age between 18 and 65
  • Chief complaint consistent with the diagnosis of headache that meets 2 of the 4 following criteria (check all that apply):
  • Unilateral Headache
  • Pulsatile Sensation
  • Moderate to Severe pain intensity
  • Aggravation by physical activity or causing avoidance of physical activity (i.e. climbing stairs, walking)
  • Headache is associated with at least one of the following symptoms (check all that apply):
  • Nausea and/or vomiting
  • Photophobia and/or phonophobia
  • History of at least 5 similar headaches
  • Within 6 hours of screening has received BOTH (via IV or PO):

    1. A Non-Steroidal Anti-Inflammatory Drug (NSAID):

      Ibuprofen / "Motrin" Naproxen / "Aleve" Ketorolac / "Toradol"

    2. A Dopamine-Antagonist:

Metoclopramide / "Reglan" Prochlorperazine / "Compazine"

  • Persists with 6/10 or greater pain at one hour after above treatment
  • Emergency Department attending feels patient appropriate for propofol treatment

Exclusion Criteria:

  • Allergy to the study medication / eggs / soy (medication components)
  • Inability to provide written, informed consent
  • Employee or in police custody
  • Pregnant or breast-feeding
  • Medical concerns: Chronic obstructive pulmonary disease, active asthma exacerbation, obstructive sleep apnea, morbid obesity (Body Mass Index > 40), American Society of Anaesthesiologists class 3 or greater, actively intoxicated, Blood Pressure < 110/70
  • Meal or heavy snack within 3 hours of sedation time
  • Will be driving themselves home from Emergency Department
  • Opioid use within the last 6 hours
  • Previously enrolled in this study

Information from the National Library of Medicine

To learn more about this study, you or your doctor may contact the study research staff using the contact information provided by the sponsor.

Please refer to this study by its ClinicalTrials.gov identifier (NCT number): NCT02492295


Locations
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United States, Pennsylvania
Albert Einstein Medical Center
Philadelphia, Pennsylvania, United States, 19141
Sponsors and Collaborators
Albert Einstein Healthcare Network
Investigators
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Principal Investigator: James Gardner, MD Albert Einstein Health Network
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Responsible Party: Albert Einstein Healthcare Network
ClinicalTrials.gov Identifier: NCT02492295    
Other Study ID Numbers: HN4616
First Posted: July 8, 2015    Key Record Dates
Results First Posted: March 19, 2020
Last Update Posted: March 19, 2020
Last Verified: May 2017
Individual Participant Data (IPD) Sharing Statement:
Plan to Share IPD: Undecided
Additional relevant MeSH terms:
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Migraine Disorders
Emergencies
Headache
Disease Attributes
Pathologic Processes
Headache Disorders, Primary
Headache Disorders
Brain Diseases
Central Nervous System Diseases
Nervous System Diseases
Pain
Neurologic Manifestations
Propofol
Hypnotics and Sedatives
Central Nervous System Depressants
Physiological Effects of Drugs
Anesthetics, Intravenous
Anesthetics, General
Anesthetics