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Intravenous Ketorolac and Metoclopramide for Pediatric Migraine in the Emergency Department (EDMigraine-4)

Primary Purpose

Probable Migraine, Migraine With Aura, Migraine Without Aura

Status
Completed
Phase
Phase 4
Locations
Canada
Study Type
Interventional
Intervention
Ketorolac Tromethamine
Metoclopramide
Sponsored by
University of Alberta
About
Eligibility
Locations
Arms
Outcomes
Full info

About this trial

This is an interventional treatment trial for Probable Migraine focused on measuring migraine, pediatric, childhood, emergency department, ketorolac, metoclopramide, intravenous

Eligibility Criteria

6 Years - 17 Years (Child)All SexesDoes not accept healthy volunteers

Inclusion Criteria:

A patient is legible to participate in this study if they meet the following criteria:

  1. Patient is between 6 and 17 years of age inclusive
  2. Treatment with usual therapy at home or at least one dose of oral ibuprofen or acetaminophen has not provided satisfactory relief
  3. Intravenous therapy is indicated in the opinion of the treating ED physician
  4. Patient has a history of migraine as defined by the International Classification of Headache Disorders - 2nd edition (Appendix 1) and meets the following criteria:

    1. During headache, at least 1 of the following: nausea and/or vomiting; two of five symptoms (photophobia, phonophobia, difficulty thinking, lightheadedness, or fatigue). Symptoms may be inferred from patient's behavior.
    2. Headache has at least 2 of the following characteristics: bifrontal/bitemporal or unilateral location; pulsating/throbbing quality; moderate or severe pain intensity; aggravation by or causing avoidance of routine physical activity. Symptoms may be inferred from patient's behavior.

Exclusion Criteria:

A patient is not eligible to participate in the study if any of the following criteria apply:

  1. Patient has a contraindication to the use of metoclopramide or ketorolac in the opinion of the ED physician
  2. Patient has a ventriculoperitoneal shunt
  3. Patient has a fever (temperature > 38.5 oC)
  4. Patient has meningismus or clinical suspicion of meningitis in the opinion of the ED physician
  5. Patient has a history of head trauma causing headache in the last 1 week prior to presentation to the ED
  6. Patient is unable to complete the efficacy assessments (e.g. language barrier)

Sites / Locations

  • Alberta Children's Hospital
  • Stollery Children's Hospital

Arms of the Study

Arm 1

Arm 2

Arm Type

Experimental

Placebo Comparator

Arm Label

Metoclopramide, Ketorolac

Metoclopramide, Placebo

Arm Description

10 mL/kg IV 0.9% sodium chloride Metoclopramide 0.2 mg/kg (max 10 mg) IV Ketorolac 0.5 mg/kg (max 30 mg) IV

10 mL/kg IV 0.9% sodium chloride Metoclopramide 0.2 mg/kg (max 10 mg) IV Placebo (normal saline)

Outcomes

Primary Outcome Measures

Mean reduction in pain intensity
Measured on Visual Analogue Scale (VAS).

Secondary Outcome Measures

Pain freedom
VAS=0
Headache relief - 33
Defined as a 33% reduction on the VAS.
Headache relief - 50
Defined as a 50% reduction on the VAS
Presence of nausea
Presence of vomiting
Use of rescue medications
Permitted per protocol 60 minutes after start if intravenous infusion.
Sustained pain-free
No recurrence of headache within 24 hours if pain was completely eliminated (VAS = 0) prior to discharge.
Sustained headache relief
No increase in headache by 33% on the VAS or 50% on the VAS if headache relief was initially achieved.
Minimum clinically significant difference
"I would take the medication again" "My headache is a bit better/worse" "My headache is a lot better/worse"
Adverse events
All serious and non-serious adverse events including akathisia and dystonia.

Full Information

First Posted
May 8, 2012
Last Updated
January 21, 2015
Sponsor
University of Alberta
Collaborators
Canadian Institutes of Health Research (CIHR)
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1. Study Identification

Unique Protocol Identification Number
NCT01596166
Brief Title
Intravenous Ketorolac and Metoclopramide for Pediatric Migraine in the Emergency Department
Acronym
EDMigraine-4
Official Title
Efficacy of Combination Therapy With Intravenous Ketorolac and Metoclopramide for Pediatric Migraine Therapy in the Emergency Department
Study Type
Interventional

2. Study Status

Record Verification Date
January 2015
Overall Recruitment Status
Completed
Study Start Date
February 2012 (undefined)
Primary Completion Date
April 2014 (Actual)
Study Completion Date
April 2014 (Actual)

3. Sponsor/Collaborators

Responsible Party, by Official Title
Sponsor
Name of the Sponsor
University of Alberta
Collaborators
Canadian Institutes of Health Research (CIHR)

4. Oversight

Data Monitoring Committee
No

5. Study Description

Brief Summary
Migraine headaches are a common problem for children. When treatment at home fails, children may benefit from intravenous treatment administered in a hospital setting like the Emergency Department. Most treatments used however have only been tested in adults and the best treatment strategy for children is not always clear. The combination of more than one medication is frequently prescribed in Canadian Emergency Departments. The purpose of this study is to investigate whether the combination of ketorolac (an anti-inflammatory pain medication) and metoclopramide (an anti-nauseant that may also relieve migraine headaches) is better than metoclopramide by itself.
Detailed Description
Migraine headache is a painful condition of recurrent moderate to severe head pain associated with nausea, vomiting, photophobia, and phonophobia. The condition is highly prevalent and a significant community health problem with considerable impact on the health care system. To alleviate the pain and morbidity associated with a migraine attack, drug therapies are often employed including simple analgesics like ibuprofen and migraine-specific medications like sumatriptan. When these treatments fail or in severe, intractable cases, patients and families may present to the Emergency Department (ED). Ketorolac in combination with metoclopramide or prochlorperazine was the most common multi-drug combination used in 36% of ED presentations for migraine across Canada in our national practice variation study. The scientific rationale for combining a non-selective non-steroidal anti-inflammatory drug (NSAID) with inhibition of both the cyclooxygenase (COX) 1 and 2 isoenzymes with other migraine therapies is enticing; however, no studies have specifically examined the relative efficacy of the practice. Why would the combination of a non-selective NSAID like ketorolac with other migraine therapies improve treatment outcomes? The benefit of multi-target combinations may be relate to the duration of the migraine and the multiple brain areas involved in sustained pain. It has long been recognized that patients who treat their migraine headaches early at the onset have a better response. The underlying mechanism for this phenomenon has now been identified. The initiation of migraine pain requires activation of the trigeminal (5th cranial nerve) nociceptive (pain) system. Activation of these sensory fibers within the arachnoid membrane on the surface of the brain produces the first and most common painful manifestation of migraine - the pulsatile headache. With each heartbeat, minor dilation of the cerebral blood vessels produces stretch and a painful activation of the trigeminal fibers known as peripheral sensitization. The second phase in the maintenance of a migraine attack over several hours is the sensitization of trigeminal pain pathways leading to higher brain centers known as central sensitization. The efficacy of medications like the triptans is greater early in the course of a migraine attack when there is only peripheral sensitization and before the onset of central sensitization. Non-selective NSAIDs like naproxen sodium and ketorolac may be uniquely effective in the reduction of central sensitization in the animal model of migraine and the reduction of migraine pain in adult patients late in the course of a migraine headache. The population of patients in the ED is uniquely different from outpatients in that most have developed their migraine headache hours or days before presenting. In our practice variation study, the mean duration of the migraine prior to presenting to the ED was 2 days. Including an NSAID when treating a prolonged migraine in the ED may thus increase the therapeutic window and improve outcomes. While many Canadian ED physicians have adopted the practice of combining ketorolac with other migraine therapies, the gold standard assessment of efficacy and safety in a randomized clinical trial has not been applied.

6. Conditions and Keywords

Primary Disease or Condition Being Studied in the Trial, or the Focus of the Study
Probable Migraine, Migraine With Aura, Migraine Without Aura
Keywords
migraine, pediatric, childhood, emergency department, ketorolac, metoclopramide, intravenous

7. Study Design

Primary Purpose
Treatment
Study Phase
Phase 4
Interventional Study Model
Parallel Assignment
Masking
ParticipantCare ProviderOutcomes Assessor
Allocation
Randomized
Enrollment
56 (Actual)

8. Arms, Groups, and Interventions

Arm Title
Metoclopramide, Ketorolac
Arm Type
Experimental
Arm Description
10 mL/kg IV 0.9% sodium chloride Metoclopramide 0.2 mg/kg (max 10 mg) IV Ketorolac 0.5 mg/kg (max 30 mg) IV
Arm Title
Metoclopramide, Placebo
Arm Type
Placebo Comparator
Arm Description
10 mL/kg IV 0.9% sodium chloride Metoclopramide 0.2 mg/kg (max 10 mg) IV Placebo (normal saline)
Intervention Type
Drug
Intervention Name(s)
Ketorolac Tromethamine
Other Intervention Name(s)
Toradol, 74103-07-4
Intervention Description
Ketorolac 0.5 mg/kg (max 30 mg) IV
Intervention Type
Drug
Intervention Name(s)
Metoclopramide
Other Intervention Name(s)
Maxeran, Reglan, 364-62-5
Intervention Description
Metoclopramide 0.2 mg/kg (max 10 mg) IV
Primary Outcome Measure Information:
Title
Mean reduction in pain intensity
Description
Measured on Visual Analogue Scale (VAS).
Time Frame
2 hours
Secondary Outcome Measure Information:
Title
Pain freedom
Description
VAS=0
Time Frame
2 hours
Title
Headache relief - 33
Description
Defined as a 33% reduction on the VAS.
Time Frame
2 hours
Title
Headache relief - 50
Description
Defined as a 50% reduction on the VAS
Time Frame
2 hours
Title
Presence of nausea
Time Frame
2 hours
Title
Presence of vomiting
Time Frame
2 hours
Title
Use of rescue medications
Description
Permitted per protocol 60 minutes after start if intravenous infusion.
Time Frame
2 hours
Title
Sustained pain-free
Description
No recurrence of headache within 24 hours if pain was completely eliminated (VAS = 0) prior to discharge.
Time Frame
25 hours
Title
Sustained headache relief
Description
No increase in headache by 33% on the VAS or 50% on the VAS if headache relief was initially achieved.
Time Frame
24 hours
Title
Minimum clinically significant difference
Description
"I would take the medication again" "My headache is a bit better/worse" "My headache is a lot better/worse"
Time Frame
2 hours
Title
Adverse events
Description
All serious and non-serious adverse events including akathisia and dystonia.
Time Frame
2 hours

10. Eligibility

Sex
All
Minimum Age & Unit of Time
6 Years
Maximum Age & Unit of Time
17 Years
Accepts Healthy Volunteers
No
Eligibility Criteria
Inclusion Criteria: A patient is legible to participate in this study if they meet the following criteria: Patient is between 6 and 17 years of age inclusive Treatment with usual therapy at home or at least one dose of oral ibuprofen or acetaminophen has not provided satisfactory relief Intravenous therapy is indicated in the opinion of the treating ED physician Patient has a history of migraine as defined by the International Classification of Headache Disorders - 2nd edition (Appendix 1) and meets the following criteria: During headache, at least 1 of the following: nausea and/or vomiting; two of five symptoms (photophobia, phonophobia, difficulty thinking, lightheadedness, or fatigue). Symptoms may be inferred from patient's behavior. Headache has at least 2 of the following characteristics: bifrontal/bitemporal or unilateral location; pulsating/throbbing quality; moderate or severe pain intensity; aggravation by or causing avoidance of routine physical activity. Symptoms may be inferred from patient's behavior. Exclusion Criteria: A patient is not eligible to participate in the study if any of the following criteria apply: Patient has a contraindication to the use of metoclopramide or ketorolac in the opinion of the ED physician Patient has a ventriculoperitoneal shunt Patient has a fever (temperature > 38.5 oC) Patient has meningismus or clinical suspicion of meningitis in the opinion of the ED physician Patient has a history of head trauma causing headache in the last 1 week prior to presentation to the ED Patient is unable to complete the efficacy assessments (e.g. language barrier)
Overall Study Officials:
First Name & Middle Initial & Last Name & Degree
Lawrence P. Richer, MD, MSc
Organizational Affiliation
University of Alberta
Official's Role
Principal Investigator
Facility Information:
Facility Name
Alberta Children's Hospital
City
Calgary
State/Province
Alberta
ZIP/Postal Code
T3B 6A8
Country
Canada
Facility Name
Stollery Children's Hospital
City
Edmonton
State/Province
Alberta
ZIP/Postal Code
T6G 2C8
Country
Canada

12. IPD Sharing Statement

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Intravenous Ketorolac and Metoclopramide for Pediatric Migraine in the Emergency Department

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