SAN FRANCISCO – Intravenous metoclopramide and diphenhydramine given together provided more effective headache relief than did codeine in pregnant women who did not respond initially to acetaminophen in an obstetrical triage unit.
Unexplained headache is a fairly common occurrence in pregnancy, estimated to occur in 15%-20% of patients, according to Dr. Katherine Scolari Childress of Saint Louis University.
Dr. Katherine Scolari Childress
Acetaminophen is the recommended first-line therapy, she said. But when it does not work, second-line therapy is more controversial. Opiates, NSAIDs, and triptans have all been used; however, these medications have been classified as category C in pregnancy, and there can be the potential for abuse, maternal dependence, neonatal withdrawal, and safety, Dr. Scolari Childress said.
She presented data on 46 normotensive pregnant women in their second or third trimester who presented with headache to an obstetric triage unit. Patients were initially treated with 650-1,000 mg of acetaminophen, which did not adequately resolve their pain. They then were randomized to receive either intravenous metoclopromide and diphenhydramine (MAD) (10 mg and 25 mg, respectively) or 30 mg oral codeine.
Patients who received MAD were significantly more likely to respond to just one dose (100% vs. 62% of patients receiving codeine), significantly more likely to experience full relief of headache pain (65% vs. 29%), and significantly more likely to say they would use the medication again (96% vs. 37%), Dr. Scolari Childress reported at the annual meeting of the American College of Obstetricians and Gynecologists.
Patients treated with MAD also spent less time on the unit – 231 minutes vs. 242 minutes for those treated with codeine – although the difference was not significant.
While the MAD regimen was more expensive than codeine – $1.54 per dose vs. $0.84 – both are low-cost treatments, she said.
Dr. Scolari Childress noted that few studies have been done on treating acute headache in pregnancy; most recommendations are based on studies of nonpregnant patients taking medications that are thought to be safe in pregnancy.
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