A new trial reports that IV sodium valproate is less effective than metoclopramide or ketorolac in the management of acute migraine (Friedman et al. Neurology 2014;82:976-983).

A total of 330 patients attending a hospital emergency room with acute migraine were randomized to sodium valproate 1000 mg, metoclopramide 10 mg or ketorolac 30 mg; all drugs were administered as an IV drip over 15 minutes. At 1 hour post-treatment, patients were asked their degree of improvement on a scale of 1 to 10.

The mean improvement was 2.8 with valproate, 4.7 with metoclopramide and 3.9 with ketorolac. Rescue medications were needed by 69%, 33% and 52%, respectively. While metoclopramide appeared to be the most effective, 6% of patients reported feeling restless after receiving the drug.

Comment:
Dr. Daniel Selchen: The value of IV valproate in acute migraine is largely a moot point in Canada given cost and issues with availability. This study suggests that we are not missing much as valproate appears to be less effective than cheaper (and not all that useful) alternatives.