PHOENIX (EGMN) – Emergency departments are good at treating headaches, but headaches often come back after discharge.

When that happens, 500 mg naproxen is as good as 100 mg sumatriptan at relieving the pain, according to a randomized clinical trial presented at the Society for Academic Emergency Medicine’s annual meeting.

The study is important because the two drugs hadn’t been compared head to head for post-ED recurrent headache, said Dr. Shujun Xia, an emergency physician at Albert Einstein College of Medicine, New York.

It was “uncertain which medication” primary headache patients should be given on discharge, said Dr. Xia, one of the study’s investigators.

Following parenteral headache treatment in the emergency department with, in most cases, metoclopramide, 410 patients were randomized to take home a capsule containing either 500 mg naproxen or 100 mg sumatriptan.

They didn’t receive prednisone before leaving the emergency department, something that has become more common in recent years to prevent headache recurrence.

If they had another headache, the patients were asked to record their initial pain on a 10-point scale and their pain 2 hours after taking the study drug. They were called 48 hours later. A total of 190 patients in the naproxen group were available for follow-up, as were 193 patients in the sumatriptan group.

A total of 73% of patients said they had a second headache, and 51% of patients – including 88 migraine patients – took the study medication.

The naproxen group reported a mean improvement of 4.3 points 2 hours after taking the drug; the sumatriptan group improved 4.1 points. The migraine subset reported a 4.3-point improvement with naproxen and a 4.2-point improvement with sumatriptan.

Gastrointestinal upset, drowsiness, dizziness, and other side effects were comparable in both groups, and about 70% of patients in both groups said they would take the study drug again (Ann. Emerg. Med. 2010;56:7-17).

The results changed the prescribing pattern of lead investigator Dr. Benjamin W. Friedman, also an emergency physician at Albert Einstein College of Medicine.

“Before, I was more likely to prescribe sumatriptan for migraine, and more likely to prescribe naproxen for nonspecific headache” following discharge, he said in an interview.

The take-home message for physicians, Dr. Friedman said, is that choosing which drug to use comes down to cost, contraindications, and prior patient experience.

Generic sumatriptan 100 mg costs about USD $24 per pill on DestinationRx.com, while 500 mg generic naproxen costs about USD $3.33 per pill. Equivalent doses of over-the-counter naproxen preparations, such as Aleve, are much less.

The study tackled a “very real clinical issue – [post-ED recurrent headache] is a common problem,” noted Dr. Edward A. Panacek, an emergency physician at the University of California, Davis, in commenting on the study.

He predicted it will reassure physicians, because most “feel more comfortable prescribing naproxen. It’s easier to get, cheap, and has fewer side effects.” However, “the fly in the ointment is that [the study] did not look at patients treated with high-dose steroids” to prevent recurrence, “a growing practice,” Dr. Panacek noted.

“That does not invalidate the study, but does limit its clinical usefulness,” said Dr. Panacek, who said he routinely gives steroids to his headache patients.

Dr. Xia and Dr. Friedman said they had no disclosures. The study was funded by Dr. Friedman’s career development award from the U.S. National Institute of Neurological Disorders and Stroke.

Copyright (c) 2010 Elsevier Global Medical News. All rights reserved. This material may not be published, broadcast, rewritten, or redistributed.

菲尼克斯(EGMN)——急诊科(ED)擅长治疗头痛，但头痛往往在患者出院后又复发。

 

据急诊医学学会年会上公布的一项随机临床试验，发生上述情况时，使用500 mg萘普生缓解疼痛与使用100 mg舒马曲坦同等有效。

 

鉴于以往研究尚未对这两种药物在急诊后复发性头痛的治疗方面进行过直接比较，故这项研究是重要的，纽约阿尔伯特爱因斯坦医学院的急诊科医生夏淑君(Shujun Xia)博士说。

 

本研究的研究者之一、夏博士说，“尚不确定”对原发性头痛患者在其出院时应给予哪种药。

 

在急诊科实施静脉用药(大多数情况下采用甲氧氯普胺)治疗头痛后，选取410例患者并随机发给他们一粒含有500 mg萘普生或100 mg舒马曲坦的胶囊带回家。

 

他们在离开急诊科之前未接受泼尼松治疗，近几年来以泼尼松预防头痛复发已成常规做法。

 

若他们头痛再次发作，则要求其在10分量表上记录初次疼痛及服用试验药后2 h的疼痛程度。48 h以后进行电话随访。萘普生治疗组共有190例患者接受随访，而舒马曲坦治疗组有193例。

 

共有73%的患者自诉又发生一次头痛，51%的患者(包括88例偏头痛患者)服用了试验药。

 

萘普生治疗组报告在服用试验药后2 h头痛程度平均改善4.3分；舒马曲坦治疗组改善4.1分。偏头痛亚组报告服用萘普生后改善4.3分，而服用舒马曲坦后改善4.2分。

 

两治疗组之间胃肠道不适、嗜睡、头晕及其他不良反应的发生情况相当，两组均有约70%的患者称会再次服用试验药(Ann. Emerg. Med. 2010;56:7-17)。

 

该研究结果改变了研究组组长、阿尔伯特爱因斯坦医学院的急诊医生Benjamin W. Friedman博士的处方习惯。

 

他在一次受访中说：“以前，我更倾向于开舒马曲坦处方治疗偏头痛，开萘普生治疗出院后的非特异性头痛。”

 

Friedman博士说，对于医生而言重要的一点是，选择药物不外乎考虑费用、禁忌证和患者既往用药史。

 

舒马曲坦100 mg在DestinationRx.com网站上购买大约花费24美元/片，而500 mg萘普生大约花费3.33美元/片。等剂量的非处方药萘普生(如Aleve)费用更低。

 

此研究处理了一个“非常现实的临床问题——急诊后复发性头痛是一个常见问题”，加州大学急诊科医生Edward A. Panacek博士在针对本研究的评论中指出。

 

他预测本研究对医生将起到定心丸的作用，原因为大多数医生“开萘普生处方时会感觉更舒心。该药易于购买、价格低廉且不良反应较少。”然而，“美中不足的是，本研究未观察高剂量甾体类药物”预防头痛复发的效果，“这种做法正日益增多”Panacek博士指出。

 

Panacek博士说：“这一点不能否定本研究的合理性，但确实限制了它的临床实用性。”他本人称常规给予头痛患者甾体类药物治疗。

 

夏博士及Friedman博士均无披露内容。该研究由美国国家神经疾病和卒中研究所通过向Friedman博士颁发杰出青年教授奖而提供资助。

 

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