Randomized trial of adding parenteral acetaminophen to prochlorperazine and diphenhydramine to treat headache in the emergency department

Abstract

Introduction: Headaches represent over three million emergency department (ED) visits per year, comprising 2.4% of all ED visits. There are many proposed methods and clinical guidelines of treating acute headache presentations. However, data on intravenous acetaminophen usage in these settings are lacking. In this study, we sought to determine the efficacy of intravenous (IV) acetam inophen as an adjunct to a standard therapy for the treatment of patients who present to the ED with a chief complaint of headache. Methods: We conducted a single site, randomized, double-blind, placebo-controlled trial investigating the clinical efficacy of IV acetaminophen as an adjunct to a sta ndard therapy with prochlorperazine and diphenhydramine for the treatment of patients who present to the ED with a chief complaint of headache or variants thereof. (See below for variants). The primary outcome measure of the efficacy of parenteral acetaminophen as an adjunct treatment for headache in addition to a standard therapy was a threshold two-point reduction in visual analog scale (VAS) pain scores on a 1-10 level at 90 minutes. Secondary outcomes measures included assessment of decreased requirement of rescue pain medicines, defined as any analgesic medications outside of diphenhydramine, prochlorperazine and acetaminophen, with particular interest to potential opioid-sparing effects with parenteral acetaminophen. Additional secondary outcome measure included time to disposition from arrival in the ED. Results: For the acetaminophen group the initial mean pain score was 8.67, for the placebo group 8.61. At 90 minutes pain score was 2.23 for the acetaminophen group and 3.99 for placebo (p<0.01, 95% confidence interval (CI) [0.8%-16%]. Of 45 patients in each grou p, we observed at least a threshold two-point decrease in pain score 36/45 (80%) with acetaminophen vs. 25/45 (55%) with placebo (p <0.01) 95% CI [5%-41%], number needed to treat (NNT) = 4). Secondary outcome measure did not demonstrate a difference in length of stay (161 minutes for acetaminophen arm and 159 minutes for placebo). However, 17/45 (38%) of patients who received IV acetaminophen require d rescue analgesia, opposed to 24/45 (53%) of patients in the placebo group (p=0.13) 95% CI [-5%-34%]. Conclusion: IV acetaminophen when used with prochlorperazine and diphenhydr amine to treat acute headaches in the ED resulted in statistically significant pain r eduction compared with prochlorperazine and diphenhydramine alone as measured by both threshold of lowe ring VAS pain score by at least two points (NNT = 4) and overall decline in VAS pain score. Further study is required to validate these results.