Use of Oral Aprepitant for the Management of Nausea with Inpatient Intravenous Dihydroergotamine (DHE) Use (S40.006)

OBJECTIVE: To assess the efficacy and tolerability of oral aprepitant in controlling nausea associated with intravenous dihydroergotamine administered for medically-refractory migraine. BACKGROUND: Intravenous DHE is an effective acute treatment for migraine. Nausea is a common side effect of DHE and its control is associated with better headache outcome. Aprepitant is a selective antagonist of the neurokinin-1 receptor that mitigates the emetic effects of substance P. It is used in the prevention of postoperative and chemotherapy-induced nausea, but has not been previously studied in the prevention of DHE-related nausea. DESIGN/METHODS: We conducted a retrospective review of patients with migrainous disorders who were admitted to the UCSF Headache Center for a five-day course of intravenous DHE (cumulative dose 11.25mg) and received oral aprepitant as adjunctive anti-emetic therapy due to refractory nausea. Peak and average daily nausea scores were determined pre- and post- aprepitant from patients' hourly diaries. The efficacy of aprepitant was assessed via the following parameters: reduction in either average or peak daily nausea rating, cessation of emesis, and ≥50% reduction in the number of PRN anti-nausea medications. RESULTS: A total of fourteen cases were identified, with admission diagnoses of chronic migraine, medication overuse, and New Daily Persistent Headache of a migrainous type. In all patients, aprepitant was effective in reducing nausea in at least one of the three outcome measures. Four patients (29%) demonstrated a response in all parameters. In all patients who developed emesis (n=8), the addition of aprepitant resulted in cessation of emesis. No side effects from aprepitant were reported by any of the patients. CONCLUSIONS: Oral aprepitant appears to be a novel, effective, and well-tolerated treatment for controlling nausea and vomiting related to intravenous DHE. Confirmation of our findings through further prospective studies would improve current intravenous DHE protocols for the treatment of refractory headache. Disclosure: Dr. Chou has nothing to disclose. Dr. Goadsby has received personal compensation for activities with Allergan, Colucid, MAP pharmaceuticals, Merck, Sharpe and Dohme, eNeura, Neuroaxon, Autonomic Technologies Inc, Boston Scientific, Eli-Lilly, Medtronic, Linde gases, Arteaus, AlderBio and BristolMyerSquibb. Dr. Goadsby has received personal compensation in an editorial capacity for Journal Watch Neurology and for developing educational materials for the American Headache Society. Dr. Goadsby has received research support from GlaxoSmithKline, MAP, MSD, eNeura, and Amgen.