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(549) Comparison of Rates of Rescue Medication, Dystonia, and Akathisia for Dopamine Antagonist Headache Medications


Elliott Chinn, n/a – Research Fellow, Albert Einstein College of Medicine (Jacobi/Montefiore)

Lauren Klein, MD, MS – Physician, Hennepin County Medical Center

Jon B. Cole, n/a – Hennepin Healthcare/Minnesota Poison Control System

Jamie Stang – Hennepin County Medical Center

Paige DeVries – Hennepin County Medical Center

Erika Mojica, n/a

Abagail Raiter

Brian Driver, MD – Emergency Physician, Hennepin County Medical Center

Elliott Chinn, n/a – Research Fellow, Albert Einstein College of Medicine (Jacobi/Montefiore)


Background and Objectives: Headache is a common presentation in the ED, accounting for over 1,000,000 annual visits in the U.S. Randomized trials in the ED have shown droperidol to be superior to the more commonly used therapies metoclopramide and prochlorperazine, however until very recently droperidol was on a prolonged shortage in the U.S. One randomized trial showed olanzapine to be equivalent to droperidol for acute primary headache in the ED; as such the use of olanzapine for headache in the ED has become common in our local practice. Given this evolution of local practice, we sought to compare olanzapine to other commonly used medications for primary headache by comparing the need for rescue medication for first-line agents in the ED.

Methods: This retrospective chart review analyzed adult (>18 years old) patients with a chief complaint of headache who received olanzapine, prochlorperazine or metoclopramide. Patients were categorized by the initial drug they received. We did not include droperidol, eletriptan or sumatriptan because of low use rates. We determined who received rescue therapy, defined as the administration of an additional headache medication in the ED at any point throughout their encounter. A trained abstractor reviewed charts to determine if patients had akathisia or dystonia. 10% of charts were reviewed to calculate interobserver agreement.

Results: 5,643 patients met inclusion criteria. Olanzapine (2994, 53%) was the most commonly first prescribed headache drug followed by prochlorperazine (2100, 37%) and metoclopramide (549, 10%) . Rates of rescue medication and 95% CI were 14.9% (12-18) for metoclopramide, 16.5% (15-18) for prochlorperazine and 18.2% (17-20) for olanzapine. Rates of dystonia were 0.2% (0-0.5) for prochlorperazine, 0.1% (0-0.2) for olanzapine and metoclopramide had zero cases of dystonia. Rates of akathisia were 1.5% (0.6-3) for metoclopramide, 1.4% (1-2) for prochlorperazine and 1.2% (0.8-1.6) for olanzapine.

Conclusion: For patients with a chief complaint of headache in the emergency department, patients who received olanzapine, metoclopramide and prochlorperazine had similar rates of need for rescue medication. Rates of akathisia and dystonia were very infrequent and comparable between all groups.

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