Antipsychotic Drug May Relieve Status Migrainosus

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Ziprasidone is known to modulate the dopaminergic system in a similar manner as droperidol and haloperidol.
Ziprasidone is known to modulate the dopaminergic system in a similar manner as droperidol and haloperidol.

An atypical antipsychotic used to treat schizophrenia may also serve as a rescue medication in patients with status migrainosus. The findings were published in The Neurohospitalist.1

Patients diagnosed as having status migrainosus have migraine symptoms that last longer than 72 hours, and are typically treated with acetaminophen, nonsteroidal anti-inflammatory drugs, and caffeine as first-line treatments, and triptans, ketorolac, prochlorperazine, or metoclopramide as second-line treatments. When those treatments fail, physicians have turned to neuroleptics and other drugs, including dopaminergic antagonists.2-4

Ziprasidone is known to modulate the dopaminergic system in a similar manner as droperidol and haloperidol, and was shown to significantly alleviate chronic daily headache.5 This prompted neurologists at Barnes-Jewish Hospital to start treating patients with status migrainosus with intramuscular ziprasidone in 2008.

In this retrospective chart review, the authors analyzed data from 43 patients with status migrainosus treated with ziprasidone between 2008 and 2015. Migraine severity data was available for 35 patients on admission and 39 patients on discharge, with a mean score of 8.9 ± 1.5 and 3.0 ± 2.9 on a 0-10 Likert scale, respectively. On average, 4.7 ± 2.5 different medications were administered prior to ziprasidone (no earlier than third-line).

Thirty-four patients had data available on admission and discharge severity scores, with an average decrease in pain of 5.7 ± 3.0. Ziprasidone was considered helpful in reducing migraine severity in 81% of cases, and was the medication linked to discharge in 65% of cases.

In order to evaluate how ziprasidone affected length of stay, the authors compared the study group who received ziprasidone with 20 patients with status migrainosus who received droperidol and other abortive treatments, excluding ziprasidone. The ziprasidone group had a median length of stay of 3 days, with a range of 1 to 8 days, while the droperidol group had a median length of stay of 4 days, with a range of 2 to 17 days. Headache recurrence occurred in 12% of patients who received ziprasidone within 30 days of initial discharge.

Adverse reactions included a period of consolidated sleep, which was reported in nearly all patients, and single reports of rhinorrhea, upper back dystonia, and asymptomatic prolongation of QTc. “Therefore, it is recommended that any patient with SM receiving ziprasidone have a baseline QTc of less than 500 milliseconds and that doses do not exceed 20 mg” of ziprasidone, the authors said.

Overall, the results suggest that ziprasidone may be an effective, fast-acting treatment for status migrainosus. Since the current study lacked a control group and consistent, systematic documentation of migraine severity and treatment results, prospective, placebo-controlled studies are needed to further confirm the safety and efficacy of ziprasidone for status migrainosus.

 

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References

  1. Landsness EC, Wang LH, Bucelli RC. Ziprasidone as a Potential Abortive Therapy for Status Migrainosus. Neurohospitalist. 2016;6(4):151-156.
  2. Honkaniemi J, Liimatainen S, Rainesalo S, Sulavuori S. Haloperidol in the Acute Treatment of Migraine: A Randomized, Double-Blind, Placebo-Controlled Study. Headache. 2006;46(5):781-787.
  3. Silberstein SD, Young WB, Mendizabal JE, Rothrock JF, Alam AS. Acute migraine treatment with droperidol: A randomized, double-blind, placebo-controlled trial. Neurology. 2003;60(2):315-321.
  4. Mascia A, Afra J, Schoenen J. Dopamine and migraine: a review of pharmacological, biochemical, neuropsychological, and therapeutic data. Cephalalgia. 1998;18(4):174-182.
  5. Cahill CM, Hardiman O, Murphy KC. Treatment of refractory chronic daily headache with the atypical antipsychotic ziprasidone – a case series. Cephalalgia. 2005;25(10):822-826.
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