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Tsze DS, Thiele C, Hirschfeld G, Dayan PS. Clinically significant differences in self-reported pain scores in children with headaches. Acad Emerg Med 2024; 31:547-554. [PMID: 38400616 DOI: 10.1111/acem.14879] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2023] [Revised: 01/05/2024] [Accepted: 01/20/2024] [Indexed: 02/25/2024]
Abstract
OBJECTIVES Changes in pain scores that represent clinically significant differences in children with headaches are necessary for study design and interpretation of findings reported in studies. We aimed to determine changes in pain scores associated with a minimum clinically significant difference (MCSD), ideal clinically significant difference (ICSD), and patient-perceived adequate analgesia (PPAA) in this population. METHODS We performed a secondary analysis of two prospective studies of children with headaches presenting to an emergency department. Two serial assessments were performed in children aged 6-17 and 4-17 years who self-reported their pain intensity using the Verbal Numerical Rating Scale (VNRS) and Faces Pain Scale-Revised (FPS-R), respectively. Children qualitatively described any endorsed change in pain score; those who received an analgesic were asked if they wanted additional analgesics to decrease their pain intensity. We used receiver operating characteristic curve-based methodology to identify changes in pain scores associated with "a little less" (MCSD) and "much less" (ICSD) pain and patients declining additional analgesics because they experienced adequate analgesia after treatment (PPAA). RESULTS We analyzed 105 children: 63.8% were female and the median (IQR) age was 13 (10-15) years. Ninety-eight children were analyzed for the VNRS and 101 were analyzed for the FPS-R. For the VNRS, raw change and percent reductions in pain scores associated with MCSD, ICSD, and PPAA were 2/10 and 25%, 4/10 and 56%, and 3/10 and 50%, respectively, and for the FPS-R, 2/10 and 25%, 4/10 and 67%, and 4/10 and 60%, respectively. The area under the curve (AUC) associated with a MCSD for both scales ranged from 94% to 98%; the AUC associated with an ICSD or PPAA for both scales ranged from 76% to 83%. CONCLUSIONS We identified changes in pain score associated with patient-centered outcomes in children with headaches suitable for designing trials and assigning clinical significance to changes in pain scores reported in studies.
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Affiliation(s)
- Daniel S Tsze
- Department of Emergency Medicine, Division of Pediatric Emergency Medicine, Columbia University College of Physicians and Surgeons, New York, New York, USA
| | - Christian Thiele
- Faculty of Business and Health, University of Applied Sciences Bielefeld, Bielefeld, Germany
| | - Gerrit Hirschfeld
- Faculty of Business and Health, University of Applied Sciences Bielefeld, Bielefeld, Germany
| | - Peter S Dayan
- Department of Emergency Medicine, Division of Pediatric Emergency Medicine, Columbia University College of Physicians and Surgeons, New York, New York, USA
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Cappellari AM, Bruschi G, Beretta GB, Molisso MT, Bertolozzi G. How Can Specialist Advice Influence the Neuroimaging Practice for Childhood Headache in Emergency Department? CHILDREN (BASEL, SWITZERLAND) 2023; 10:1837. [PMID: 38136039 PMCID: PMC10742139 DOI: 10.3390/children10121837] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Revised: 11/17/2023] [Accepted: 11/20/2023] [Indexed: 12/24/2023]
Abstract
Differentiating between primary and secondary headaches can be challenging, especially in the emergency department (ED). Since symptoms alone are inadequate criteria for distinguishing between primary and secondary headaches, many children with headaches undergo neuroimaging investigations, such as brain CT and MRI. In various studies, the frequency of neuroimaging utilization is influenced by several factors, including teaching status, ownership, metropolitan area, insurance status, and ethnicity of patients. However, only a few studies have considered the role of specialist consultations in ordering neuroimaging studies on childhood headaches. We report the contributions of different specialists to the evaluation of children with headaches admitted to the ED and their influence on neuroimaging decisions. We retrospectively reviewed the medical reports of paediatric patients who presented with headaches to the paediatric ED of the Ospedale Maggiore Policlinico of Milano between January 2017 and January 2022. Overall, 890 children with headaches were evaluated (mean age: 10.0 years; range: 1 to 17 years). All patients were examined by the ED paediatricians, while specialist consultations were required for 261 patients, including 240 neurological (92.0%), 46 ophthalmological (17.6%), and 20 otorhinolaryngological (7.7%) consultations. Overall, 173 neuroimaging examinations were required, of which 51.4 and 48.6% were ordered by paediatricians and neurologists, respectively. In particular, paediatricians required 61.4% of brain CT scans, and neurologists required 92.0% of brain MRI scans. In conclusion, paediatricians were responsible for the management of most children with headaches admitted to the ED, while specialist consultations were required only in about a third of the cases. Although there was no significant difference in the number of neuroimaging studies ordered by specialists, brain CT scans were most often used by paediatricians, and MRI scans by neurologists.
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Affiliation(s)
- Alberto M. Cappellari
- Department of Neuroscience and Mental Health, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy;
| | - Gaia Bruschi
- Postgraduate School of Paediatrics, Università degli Studi di Milano, 20122 Milan, Italy; (G.B.); (G.B.B.)
| | - Gisella B. Beretta
- Postgraduate School of Paediatrics, Università degli Studi di Milano, 20122 Milan, Italy; (G.B.); (G.B.B.)
| | - Maria T. Molisso
- Department of Neuroscience and Mental Health, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy;
| | - Giuseppe Bertolozzi
- Pediatric Emergency Department, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy;
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3
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Genadry KC, Monuteaux MC, Neuman MI, Lowe DA, Lee LK. Disparities and Trends in Migraine Management in Pediatric Emergency Departments, 2009-19. Acad Pediatr 2023; 23:76-84. [PMID: 35609775 DOI: 10.1016/j.acap.2022.04.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2021] [Revised: 04/15/2022] [Accepted: 04/15/2022] [Indexed: 01/19/2023]
Abstract
OBJECTIVE To assess the variation in migraine management over time across US children's hospitals and to identify factors associated with disparities in management. METHODS We conducted a retrospective study of 32 hospitals in the Pediatric Health Information System from 2009 to 2019. We included children 7 to 21 years old with primary ICD-9 or ICD-10 diagnosis codes for migraine headache. We surveyed hospitals to assess for clinical guideline presence. We assessed medication use trends over time. To examine differences in medication and advanced head imaging use by patient characteristics and presence of clinical guideline, we performed multivariable logistic regression analyses reporting adjusted odds ratios (aOR) with 95% confidence intervals (CI). RESULTS We identified 112,077 eligible visits. Opioid use decreased over time, while nonopioid analgesic, dopamine antagonist, and diphenhydramine use increased. Multivariable analysis for opioids revealed increased odds of use for those 14 to 17 (aOR 1.19; 95% CI, 1.06, 1.34) and 18 to 21 years old (aOR 1.69; CI, 1.37, 2.08), and clinical guideline presence had decreased odds (aOR 0.64; CI, 0.48, 0.84). For head computed tomography, increased odds of use were reported for Hispanic ethnicity (aOR 1.15; CI, 1.06, 1.24) and decreased odds for 14 to 17 years (aOR 0.85; CI, 0.80, 0.90), 18 to 21 years (aOR 0.87; CI, 0.77, 0.98), and female sex (aOR 0.74; CI, 0.70, 0.79). CONCLUSIONS Opioid use decreased while other medications increased over time. Medication and imaging differed by demographic characteristics. Opioid use was less likely in hospitals with clinical guidelines. Standardization in management may decrease care disparities and variability.
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Affiliation(s)
- Katia C Genadry
- Department of Pediatrics, Division of Emergency Medicine, Boston Children's Hospital, Harvard Medical School (KC Genadry, MC Monuteaux, MI Neuman, and LK Lee), Boston, Mass.
| | - Michael C Monuteaux
- Department of Pediatrics, Division of Emergency Medicine, Boston Children's Hospital, Harvard Medical School (KC Genadry, MC Monuteaux, MI Neuman, and LK Lee), Boston, Mass
| | - Mark I Neuman
- Department of Pediatrics, Division of Emergency Medicine, Boston Children's Hospital, Harvard Medical School (KC Genadry, MC Monuteaux, MI Neuman, and LK Lee), Boston, Mass
| | - David A Lowe
- Department of Emergency Medicine, Nicklaus Children's Hospital (DA Lowe), Miami, Fla
| | - Lois K Lee
- Department of Pediatrics, Division of Emergency Medicine, Boston Children's Hospital, Harvard Medical School (KC Genadry, MC Monuteaux, MI Neuman, and LK Lee), Boston, Mass
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Abstract
Headache represents one of the most common disorders in childhood and leads to nearly half a million visits to the physician's office or emergency department every year. Although the estimated prevalence is around 58.4%, the actual incidence of headache in the pediatric population might be underestimated, given only a percentage of cases seek medical attention. The first step in the evaluation of pediatric headache is a detailed clinical history and relevant clinical examinations. AAN and ACR do not recommend neuroimaging for patients with primary headache. However, neuroimaging becomes mandatory in presence of red flags to rule out the underlying cause.
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Affiliation(s)
- Aline Camargo
- Radiology Research, Division of Neuroradiology, Penn State Health, Penn State College of Medicine, Mail Code H066 500 University Drive, Hershey, PA 17033, USA
| | - Sangam Kanekar
- Radiology Research, Division of Neuroradiology, Penn State Health, Penn State College of Medicine, Mail Code H066 500 University Drive, Hershey, PA 17033, USA.
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Maki K, Doan Q, Sih K, Stillwell K, Chun A, Meckler G. A randomized controlled pilot study of intranasal lidocaine in acute management of paediatric migraine and migraine-like headache. Paediatr Child Health 2022; 27:340-345. [DOI: 10.1093/pch/pxac054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2021] [Accepted: 05/05/2022] [Indexed: 11/14/2022] Open
Abstract
Abstract
Objectives
This study was aimed to determine the sample size required to conduct an efficacy randomized controlled trial (RCT) to evaluate superiority of intranasal (IN) lidocaine to placebo as an analgesic option for children presenting to the paediatric emergency department (PED) with migraine or posttraumatic headache with migraine features and to evaluate study protocol feasibility.
Study Design
This study is a double-blind RCT of children aged 7 to 16 years at a single-centre PED. Thirty-two participants were randomized to receive either IN 2% lidocaine or 0.9% sodium chloride. The primary outcome measure was the proportion of subjects with a Verbal Numeric Rating Scale pain score of <4 at 30 and 60 minutes post-IN therapy. Primary outcome data were analyzed using a test of differences between proportions. Secondary objectives included assessing the feasibility of our study protocol by evaluating recruitment rates, adverse drug events, and PED length of stay (LOS).
Results
Six of 17 participants in the lidocaine group and 2 of 15 in the placebo group were treated successfully. Using these proportions with 95% confidence intervals and 80% power, the sample size required to find a significant difference between proportions would be 67 participants per arm. Our enrolment rate was 55% and there were no serious adverse drug events. The median PED LOS was similar between groups.
Conclusion
We determined the sample size required to conduct a definitive RCT to evaluate the superiority of IN lidocaine to placebo and found the study protocol is feasible but identified important considerations in PED migraine trial design.
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Affiliation(s)
- Kate Maki
- Department of Pediatrics, University of British Columbia , Vancouver, British Columbia , Canada
| | - Quynh Doan
- Department of Pediatrics, University of British Columbia , Vancouver, British Columbia , Canada
- BC Children’s Hospital Research Institute , Vancouver, British Columbia , Canada
| | - Kendra Sih
- Department of Pediatrics, University of British Columbia , Vancouver, British Columbia , Canada
| | - Karly Stillwell
- BC Children’s Hospital Research Institute , Vancouver, British Columbia , Canada
| | - Alaina Chun
- BC Children’s Hospital Research Institute , Vancouver, British Columbia , Canada
| | - Garth Meckler
- Department of Pediatrics, University of British Columbia , Vancouver, British Columbia , Canada
- BC Children’s Hospital Research Institute , Vancouver, British Columbia , Canada
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Tsze DS, Lubell TR, Carter RC, Chernick LS, DePeter KC, McLaren SH, Kwok MY, Roskind CG, Gonzalez AE, Fan W, Babineau SE, Friedman BW, Dayan PS. Intranasal ketorolac versus intravenous ketorolac for treatment of migraine headaches in children: A randomized clinical trial. Acad Emerg Med 2022; 29:465-475. [PMID: 34822214 PMCID: PMC10695685 DOI: 10.1111/acem.14422] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Revised: 10/31/2021] [Accepted: 11/21/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Intravenous ketorolac is commonly used for treating migraine headaches in children. However, the prerequisite placement of an intravenous line can be technically challenging, time-consuming, and associated with pain and distress. Intranasal ketorolac may be an effective alternative that is needle-free and easier to administer. We aimed to determine whether intranasal ketorolac is non-inferior to intravenous ketorolac for reducing pain in children with migraine headaches. METHODS We conducted a randomized double-blind non-inferiority clinical trial. Children aged 8-17 years with migraine headaches, moderate to severe pain, and requiring parenteral analgesics received intranasal ketorolac (1 mg/kg) or intravenous ketorolac (0.5 mg/kg). Primary outcome was reduction in pain at 60 min after administration measured using the Faces Pain Scale-Revised (scored 0-10). Non-inferiority margin was 2/10. Secondary outcomes included time to onset of clinically meaningful decrease in pain; ancillary emergency department outcomes (e.g. receipt of rescue medications, headache relief, headache freedom, percentage improvement); 24-h follow-up outcomes; functional disability; and adverse events. RESULTS Fifty-nine children were enrolled. We analyzed 27 children who received intranasal ketorolac and 29 who received intravenous ketorolac. The difference in mean pain reduction at 60 min between groups was 0.2 (95% CI -0.9, 1.3), with the upper limit of the 95% CI being less than the non-inferiority margin. There were no statistical differences between groups for secondary outcomes. CONCLUSIONS Intranasal ketorolac was non-inferior to intravenous ketorolac for reducing migraine headache pain in the emergency department.
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Affiliation(s)
- Daniel S. Tsze
- Department of Emergency Medicine, Division of Pediatric Emergency Medicine, Columbia University College of Physicians and Surgeons, New York, New York, USA
| | - Tamar R. Lubell
- Department of Emergency Medicine, Division of Pediatric Emergency Medicine, Columbia University College of Physicians and Surgeons, New York, New York, USA
| | - Robert C. Carter
- Department of Emergency Medicine, Division of Pediatric Emergency Medicine, Columbia University College of Physicians and Surgeons, New York, New York, USA
| | - Lauren S. Chernick
- Department of Emergency Medicine, Division of Pediatric Emergency Medicine, Columbia University College of Physicians and Surgeons, New York, New York, USA
| | - Kerrin C. DePeter
- Department of Emergency Medicine, Division of Pediatric Emergency Medicine, Columbia University College of Physicians and Surgeons, New York, New York, USA
| | - Son H. McLaren
- Department of Emergency Medicine, Division of Pediatric Emergency Medicine, Columbia University College of Physicians and Surgeons, New York, New York, USA
| | - Maria Y. Kwok
- Department of Emergency Medicine, Division of Pediatric Emergency Medicine, Columbia University College of Physicians and Surgeons, New York, New York, USA
| | - Cindy G. Roskind
- Department of Emergency Medicine, Division of Pediatric Emergency Medicine, Columbia University College of Physicians and Surgeons, New York, New York, USA
| | - Ariana E. Gonzalez
- Department of Emergency Medicine, Division of Pediatric Emergency Medicine, Columbia University College of Physicians and Surgeons, New York, New York, USA
| | - Weijia Fan
- Department of Biostatistics, Mailman School of Public Health, Columbia University, New York, New York, USA
| | - Shannon E. Babineau
- Departments of Pediatrics and Neurology, Sidney Kimmel Medical College of Thomas Jefferson University, Morristown, New Jersey, USA
| | - Benjamin W. Friedman
- Department of Emergency Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, New York, USA
| | - Peter S. Dayan
- Department of Emergency Medicine, Division of Pediatric Emergency Medicine, Columbia University College of Physicians and Surgeons, New York, New York, USA
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Esparham A, Boorigie M, Ablatt S, Connelly M, Bickel J. Improving Acute Treatment of Pediatric Primary Headache Disorders With a Novel Headache Treatment Center: Retrospective Review of Preliminary Outcomes. J Child Neurol 2021; 36:54-59. [PMID: 32873117 DOI: 10.1177/0883073820952997] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To determine preliminary outcomes of targeted headache treatments provided at a novel outpatient acute care pediatric headache treatment center. BACKGROUND Limitations exist in acute management of pediatric headaches, including inadequate access to specialty headache therapies and headache specialists in acute settings, variable success of emergency room treatments, and omission of comfort measures. An outpatient acute headache care clinic (the "Headache Treatment Center") was strategically initiated at a Midwestern pediatric academic hospital to provide acute and targeted headache therapies for children with active headaches. METHODS We conducted a retrospective chart review of 154 visits from September through November 2018 of patients ages 7-18 years visiting the Headache Treatment Center. RESULTS On average, headache intensity (measured on an 11-point pain numeric rating scale) decreased after interventions used in the Headache Treatment Center (mean change = 2.85 ± 2.81, P < .05, Cohen d = 1.01). Large effect sizes for reducing headache intensity were observed for pericranial, occipital/auriculotemporal, and occipital nerve blocks, Cohen d = 1.56, 1.64 and 1.02, respectively. Large effect sizes for reducing headache intensity also were observed for a transcutaneous supraorbital nerve stimulator device (Cefaly) (Cohen d = 1.02), acupuncture (Cohen d = 1.09), and intravenous migraine cocktails (Cohen d = 0.91-1.34). CONCLUSION Targeted headache therapies to abort pediatric primary headaches as part of a novel headache clinic model may be beneficial for short-term management.
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Affiliation(s)
- Anna Esparham
- 4204Children's Mercy Hospitals and Clinics, Kansas City, MO, USA
| | | | - Saniya Ablatt
- 4204Children's Mercy Hospitals and Clinics, Kansas City, MO, USA
| | - Mark Connelly
- 4204Children's Mercy Hospitals and Clinics, Kansas City, MO, USA
| | - Jennifer Bickel
- 4204Children's Mercy Hospitals and Clinics, Kansas City, MO, USA
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Clinical Factors Associated With Pediatric Brain Neoplasms Versus Primary Headache: A Case-Control Analysis. Pediatr Emerg Care 2020; 36:459-463. [PMID: 29135901 DOI: 10.1097/pec.0000000000001347] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Pediatric headaches are a common presentation to emergency departments accounting for almost half a million annual visits. Providers are left with the difficult task of deciding who has a secondary headache etiology that warrants neuroimaging. METHODS We conducted a retrospective case-control study. Patients from a pediatric neuro-oncology clinic database with brain cancer and a headache at presentation were identified as cases. Controls were patients from 2 local pediatric tertiary care emergency departments with a final diagnosis of headache after negative neuroimaging. Clinical factors were decided a priori, and logistic regression was used to determine which clinical factors were related to case/control status. RESULTS A total of 334 patients (203 controls and 131 cases) were included. Patients with a history of headaches had 0.5 (95% confidence interval [CI]: 0.3-0.9; P = 0.03) times the odds of being a case. Patients with vomiting had increased odds of being a case compared with controls regardless of the time of day (early morning 1.8 [95% CI: 1.0-3.2; P = 0.04] and non-early morning 6.6 [95% CI: 2.0-21.7; P < 0.01]). Patients with neurological signs had 10.3 (95% CI: 5.4-19.4; P < 0.01) times the odds of being a case, and patients with an associated seizure had 10.9 (95% CI: 3.8-30.7; P < 0.01) times the odds of being a case. CONCLUSIONS This study identified clinical factors associated with pediatric brain neoplasms that may guide acute neuroimaging decisions. This study also provides insight into potential clinical factors to be studied prospectively to derive a clinical decision rule.
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Tsze DS, Ochs JB, Gonzalez AE, Dayan PS. Red flag findings in children with headaches: Prevalence and association with emergency department neuroimaging. Cephalalgia 2019; 39:185-196. [PMID: 29874930 PMCID: PMC10693908 DOI: 10.1177/0333102418781814] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2023]
Abstract
BACKGROUND Clinicians appear to obtain emergent neuroimaging for children with headaches based on the presence of red flag findings. However, little data exists regarding the prevalence of these findings in emergency department populations, and whether the identification of red flag findings is associated with potentially unnecessary emergency department neuroimaging. OBJECTIVES We aimed to determine the prevalence of red flag findings and their association with neuroimaging in otherwise healthy children presenting with headaches to the emergency department. Our secondary aim was to determine the prevalence of emergent intracranial abnormalities in this population. METHODS A prospective cohort study of otherwise healthy children 2-17 years of age presenting to an urban pediatric emergency department with non-traumatic headaches was undertaken. Emergency department physicians completed a standardized form to document headache descriptors and characteristics, associated symptoms, and physical and neurological exam findings. Children who did not receive emergency department neuroimaging received 4-month telephone follow-up. Outcomes included emergency department neuroimaging and the presence of emergent intracranial abnormalities. RESULTS We enrolled 224 patients; 197 (87.9%) had at least one red flag finding on history. Several red flag findings were reported by more than a third of children, including: Headache waking from sleep (34.8%); headache present with or soon after waking (39.7%); or headaches increasing in frequency, duration and severity (40%, 33.1%, and 46.3%). Thirty-three percent of children received emergency department neuroimaging. The prevalence of emergent intracranial abnormalities was 1% (95% CI 0.1, 3.6). Abnormal neurological exam, extreme pain intensity of presenting headache, vomiting, and positional symptoms were independently associated with emergency department neuroimaging. CONCLUSIONS Red flag findings are common in children presenting with headaches to the emergency department. The presence of red flag findings is associated with emergency department neuroimaging, although the risk of emergent intracranial abnormalities is low. Many children with headaches may be receiving unnecessary neuroimaging due to the high prevalence of non-specific red flag findings.
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Affiliation(s)
- Daniel S Tsze
- Division of Pediatric Emergency Medicine, Columbia University College of Physicians and Surgeons, New York, NY, USA
| | - Julie B Ochs
- Division of Pediatric Emergency Medicine, Columbia University College of Physicians and Surgeons, New York, NY, USA
| | - Ariana E Gonzalez
- Division of Pediatric Emergency Medicine, Columbia University College of Physicians and Surgeons, New York, NY, USA
| | - Peter S Dayan
- Division of Pediatric Emergency Medicine, Columbia University College of Physicians and Surgeons, New York, NY, USA
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10
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Orr SL, Richer L, Barrowman N, Zemek R. Oral dexamethasone for the prevention of acute migraine recurrence in pediatric patients presenting to the emergency department with migraine. CEPHALALGIA REPORTS 2018. [DOI: 10.1177/2515816318804158] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
Objective: To assess the feasibility of a randomized controlled trial protocol that aims to determine the efficacy and safety of oral dexamethasone compared to placebo for the prevention of migraine recurrence in children and adolescents visiting the pediatric emergency department (ED) with migraine. Methods: This study was a two-arm, parallel-group, randomized, placebo-controlled, double-blind pilot trial of patients presenting to the pediatric ED with migraine. Eligible participants were randomized at 1:1 ratio to receive either oral dexamethasone 0.6 mg/kg (maximum 15 mg) or matched placebo as a single dose. Efficacy and safety outcomes were assessed at discharge, 48 h and 7 days after discharge. The primary outcome of the trial was feasibility and was assessed through participant recruitment rate, follow-up completion rates, participant satisfaction ratings and comparison of enrolled versus non-enrolled participants. Efficacy and safety outcomes were not analyzed given that this was a pilot study. Results: Twelve participants were enrolled over the 6-month recruitment period. This represents 60% of the planned sample size and a 10.5% recruitment rate. No other feasibility issues were identified and patients expressed high satisfaction rates with their treatment: 90.9% were satisfied with their treatment at discharge and at 48-h follow-up and 81.8% were satisfied with their treatment at 7-day follow-up (81.8%). There were no significant differences observed when comparing enrolled participants to those not enrolled. Conclusion: This pilot randomized controlled trial is the first to assess dexamethasone in the pediatric ED for the prevention of migraine recurrence. The protocol is feasible but recruitment in a single center was lower than expected. Future pediatric ED migraine studies may use innovative or pragmatic trial designs to maximize feasibility from a recruitment standpoint.
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Affiliation(s)
- Serena L Orr
- Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA
| | - Lawrence Richer
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
- Women and Children’s Health Research Institute, Edmonton, Alberta, Canada
| | - Nick Barrowman
- Children’s Hospital of Eastern Ontario, Ottawa, Ontario, Canada
- Department of Pediatrics, University of Ottawa, Ottawa, Ontario, Canada
| | - Roger Zemek
- Children’s Hospital of Eastern Ontario, Ottawa, Ontario, Canada
- Department of Pediatrics, University of Ottawa, Ottawa, Ontario, Canada
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Orr SL, Kabbouche MA, Horn PS, O'Brien HL, Kacperski J, LeCates S, White S, Weberding J, Miller MN, Powers SW, Hershey AD. Predictors of First-Line Treatment Success in Children and Adolescents Visiting an Infusion Center for Acute Migraine. Headache 2018; 58:1194-1202. [DOI: 10.1111/head.13340] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/16/2018] [Indexed: 12/16/2022]
Affiliation(s)
- Serena L. Orr
- Division of Neurology; Cincinnati Children's Hospital Medical Center; Cincinnati OH USA
| | - Marielle A. Kabbouche
- Division of Neurology; Cincinnati Children's Hospital Medical Center; Cincinnati OH USA
| | - Paul S. Horn
- Division of Neurology; Cincinnati Children's Hospital Medical Center; Cincinnati OH USA
| | - Hope L. O'Brien
- Division of Neurology; Cincinnati Children's Hospital Medical Center; Cincinnati OH USA
| | - Joanne Kacperski
- Division of Neurology; Cincinnati Children's Hospital Medical Center; Cincinnati OH USA
| | - Susan LeCates
- Division of Neurology; Cincinnati Children's Hospital Medical Center; Cincinnati OH USA
| | - Shannon White
- Division of Neurology; Cincinnati Children's Hospital Medical Center; Cincinnati OH USA
| | - Jessica Weberding
- Division of Neurology; Cincinnati Children's Hospital Medical Center; Cincinnati OH USA
| | - Mimi N. Miller
- Division of Neurology; Cincinnati Children's Hospital Medical Center; Cincinnati OH USA
| | - Scott W. Powers
- Division of Neurology; Cincinnati Children's Hospital Medical Center; Cincinnati OH USA
| | - Andrew D. Hershey
- Division of Neurology; Cincinnati Children's Hospital Medical Center; Cincinnati OH USA
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Abstract
Migraine headache is a neurologic disorder that occurs in 18% of women and 6% of men. Adults and children with mild to moderate migraine headaches seeking acute therapy should be treated with nonsteroidal anti-inflammatory drugs because of the efficacy, cost, and decreased side effects. Some children and adults require preventive therapy (those with headaches lasting >12 h, those patients with >4 headaches in 1 month, those with headaches that affect their ability to function). Studies have shown that early treatment with large doses of medication work well for the treatment of moderate to severe migraine headache.
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Affiliation(s)
- Tomia Palmer Harmon
- Department of Clinical Education, Georgia Campus, Philadelphia College of Osteopathic Medicine, 625 Old Peachtree Road, Northwest, Suwanee, GA 30024, USA.
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13
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Papetti L, Capuano A, Tarantino S, Vigevano F, Valeriani M. Headache as an Emergency in Children and Adolescents. Curr Pain Headache Rep 2015; 19:3. [DOI: 10.1007/s11916-015-0480-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
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14
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Massano D, Julliand S, Kanagarajah L, Gautier M, Vizeneux A, Elmaleh M, Alison M, Lejay E, Romanello S, Teisseyre L, Delanoe C, Titomanlio L. Headache with focal neurologic signs in children at the emergency department. J Pediatr 2014; 165:376-82. [PMID: 24928695 DOI: 10.1016/j.jpeds.2014.04.053] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2013] [Revised: 03/18/2014] [Accepted: 04/29/2014] [Indexed: 12/17/2022]
Abstract
OBJECTIVE To identify predictors of secondary headache in children consulting at the pediatric emergency department (ED) for headache with a focal neurologic deficit. STUDY DESIGN In this prospective cohort study, we enrolled children aged 6-18 years presenting to the ED of a tertiary care hospital with moderate to severe headache and focal neurologic deficit. Enrollment took place between March 2009 and February 2012. Children with a history of trauma, fever, or neurosurgical intervention were excluded from the study. The final diagnosis was made after 1 year of follow-up. Our primary aim was to identify any differences in the frequency of clinical signs between children with a final diagnosis of primary headache and those with a final diagnosis of secondary headache. RESULTS Of the 101 patients included in the study, 66% received a final diagnosis of primary headache (94% migraine with aura), and 34% received a final diagnosis of secondary headache (76.5% focal epilepsy). On multivariate analysis, children with bilateral localization of pain had a higher likelihood (aOR, 8.6; 95% CI, 3.2-23.2; P<.001) of having secondary headache. CONCLUSION Among children presenting to the ED with focal neurologic deficits, a bilateral headache location was associated with higher odds of having a secondary cause of headache. Additional longitudinal studies are needed to investigate whether our data can aid management in the ED setting.
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Affiliation(s)
- Davide Massano
- Pediatric Emergency Department, Robert Debré Hospital-Assistance Publique Hôpitaux de Paris, Paris Diderot University, Paris, France; Pediatric Migraine and Neurovascular Diseases Clinic, Robert Debré Hospital-Assistance Publique Hôpitaux de Paris, Paris Diderot University, Paris, France
| | - Sebastien Julliand
- Pediatric Emergency Department, Robert Debré Hospital-Assistance Publique Hôpitaux de Paris, Paris Diderot University, Paris, France
| | - Lakshmi Kanagarajah
- Department of Radiology, Basildon University Hospital, Essex, United Kingdom
| | - Maxime Gautier
- Pediatric Migraine and Neurovascular Diseases Clinic, Robert Debré Hospital-Assistance Publique Hôpitaux de Paris, Paris Diderot University, Paris, France
| | - Audrey Vizeneux
- Pediatric Migraine and Neurovascular Diseases Clinic, Robert Debré Hospital-Assistance Publique Hôpitaux de Paris, Paris Diderot University, Paris, France
| | - Monique Elmaleh
- Pediatric Radiology Department, Robert Debré Hospital-Assistance Publique Hôpitaux de Paris, Paris Diderot University, Paris, France
| | - Marianne Alison
- Pediatric Radiology Department, Robert Debré Hospital-Assistance Publique Hôpitaux de Paris, Paris Diderot University, Paris, France
| | - Emilie Lejay
- Pediatric Emergency Department, Robert Debré Hospital-Assistance Publique Hôpitaux de Paris, Paris Diderot University, Paris, France
| | - Silvia Romanello
- Pediatric Migraine and Neurovascular Diseases Clinic, Robert Debré Hospital-Assistance Publique Hôpitaux de Paris, Paris Diderot University, Paris, France
| | - Laurence Teisseyre
- Pediatric Migraine and Neurovascular Diseases Clinic, Robert Debré Hospital-Assistance Publique Hôpitaux de Paris, Paris Diderot University, Paris, France
| | - Catherine Delanoe
- Neurophysiology Unit, Robert Debré Hospital-Assistance Publique Hôpitaux de Paris, Paris Diderot University, Paris, France
| | - Luigi Titomanlio
- Pediatric Emergency Department, Robert Debré Hospital-Assistance Publique Hôpitaux de Paris, Paris Diderot University, Paris, France; Pediatric Migraine and Neurovascular Diseases Clinic, Robert Debré Hospital-Assistance Publique Hôpitaux de Paris, Paris Diderot University, Paris, France.
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15
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Minen MT, Tanev K, Friedman BW. Evaluation and treatment of migraine in the emergency department: a review. Headache 2014; 54:1131-45. [PMID: 24898930 DOI: 10.1111/head.12399] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/17/2014] [Indexed: 11/28/2022]
Abstract
Head pain is the fifth most common reason for emergency department (ED) visits. It is second only to focal weakness as the most common reason for neurological consultation in the ED. This manuscript reviews how patients with migraine, the most common primary headache disorder for which patients seek medical treatment, are managed in the ED. We discuss existing guidelines for head imaging in patients with migraine, recommended pharmacologic treatments, and current treatment trends. We also review studies evaluating the discharge care of migraine patients in the ED. With the goal of standardizing, streamlining, and optimizing ED-based migraine care, we offer ideas for future research to improve the evaluation, treatment, and discharge care of patients who present to an ED with acute migraine.
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Affiliation(s)
- Mia T Minen
- Graham Headache Center, Department of Neurology, Brigham and Women's Faulkner Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
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16
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Sheridan DC, Spiro DM, Meckler GD. Pediatric migraine: abortive management in the emergency department. Headache 2013; 54:235-45. [PMID: 24512575 DOI: 10.1111/head.12253] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/09/2013] [Indexed: 12/23/2022]
Abstract
Studies suggest that headache accounts for approximately 1% of pediatric emergency department (ED) visits. ED physicians must distinguish between primary headaches, such as a tension or migraine, and secondary headaches caused by systemic disease including neoplasm, infection, or intracranial hemorrhage. A recent study found that 40% of children presenting to the ED with headache were diagnosed with a primary headache, and 75% of these were migraine. Once the diagnosis of migraine has been made, the ED physician is faced with the challenge of determining appropriate abortive treatment. This review summarizes the most recent literature on pediatric migraine with an emphasis on diagnosis and abortive treatment in the ED.
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Affiliation(s)
- David C Sheridan
- Department of Emergency Medicine/Pediatrics, Oregon Health & Science University, Portland, OR, USA
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