Written by Doug Wallace
Spoon Feed
In this randomized controlled trial, adding 1 liter of IV normal saline to intramuscular diclofenac for acute migraine in the ED did not significantly improve pain relief at 2 hours compared with diclofenac alone.
Just add fluids? Not so fast
This single-center RCT enrolled 125 adult migraine patients to receive 75 mg IM diclofenac plus either 1,000 mL IV saline over 1 hour or a minimal 10 mL infusion placebo. The primary outcome was change in a visual analog scale (VAS) pain score at 2 hours.
Pain improved substantially in both groups. Median VAS reduction was 62 in the fluid group versus 48 in controls, with an estimated between-group difference of 10 (95%CI −2 to 20), not meeting statistical or clear clinical significance. Nausea scores and functional disability were similarly improved without meaningful differences.
Rescue medication use was lower in the fluid group (23.8% vs. 42.5%, absolute difference 18.6%), and ED length of stay was modestly shorter (median difference 19 minutes). However, staff were unblinded, which raises the possibility of bias in administration of rescue medication. No serious adverse events occurred.
How will this change my practice?
IV fluids were taught to me as part of the classic “migraine cocktail,” and I order them frequently for headache patients. This study suggests that for uncomplicated migraine without dehydration, 1 liter of saline does not meaningfully enhance NSAID-driven pain relief. I’ll consider fluids in the future for patients who actually look dry, rather than reflexively spiking a liter for every migraine.
Source
Efficacy of Adding Intravenous Saline Solution to Nonsteroidal Anti-Inflammatory Drug-Based Treatment of Acute Migraine in the Emergency Department. Ann Emerg Med. 2026 Feb;87(2):157-166. doi: 10.1016/j.annemergmed.2025.09.013. Epub 2025 Oct 10. PMID: 41071134.
