IV valproate inferior for acute migraine

Friedman BW, Garber L, Yoon A, et al.  Randomized trial of iv valproate vs.metoclopramide v. ketorolac for acute migraine.  Neurology 2014; 82:976-983.

 

Authors randomized 330 patients in ER to get 1000 mg, 10 mg, or 30 mg of respective drugs above over an iv drip over 15 minutes in a double blind trial.  On the primary measure of pain relief, valproate lost big to the other two drugs.  On secondary measures of needing a rescue medication, iv valproate also lost.

 

Comment-- great to have this knowledge but the two winning drugs each had relatively low sustained headache relief, 4 v. 11 v. 16 % with respective drugs above.  Also metoclopramide made people feel restless.

GPDS and NCSE

Foreman BM, Chassen J, Abou Khaled K, et al. Generalized periodic discharges in the critically ill:  a case control study of 200 patients.  Neurology 2012; 79:1951-1960

 

and editorial Jette N, Mosely BD. Generalized periodic discharges : More light shed on the old GPEDs Neurology 2012; 79: 1940-1.

 

Authors found GPD's in 4.5 % of 3000 patients undergoing cEEG.  These 200 patients  had brain injury (44%), acute systemic illness (38%), cardiac arrest (15%) and epilepsy (3%). 

 

27 % of GPD's had NCSE v. 8 % of controls.  However, GPD's were not associated with convulsive seizures. 

 

Authors/editorial notes that the distinction and semiology of GPD's v. triphasic waves is "challenging" even for board certified epileptologists. 

 

Take home messages, per the editorial are:

1) Patients with GPD's on routine EEG should undergo cEEG

2)  NCSE should be promptly treated when diagnosed to prevent mortality

3) Standard terminology and interrater reliability should be assessed within institutional readers.