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Bengio M, Goodwin G, Roka A, Marin M. Pediatric headache patient with cerebral abscesses: a brief review of the literature and case report. J Int Med Res 2023; 51:3000605231213751. [PMID: 38006608 PMCID: PMC10683565 DOI: 10.1177/03000605231213751] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Accepted: 10/26/2023] [Indexed: 11/27/2023] Open
Abstract
BACKGROUND Pediatric headache is a common cause of pediatric emergency department (ED) visits, and 8.8% of cases require imaging. Alarmingly, 12.5% of imaged cases have a pathologic cause. A pediatric patient with a complicated medical history presented to the pediatric ED with multiple cerebral abscesses. The possible causes and contributors to this rare cause of pediatric headache and a review of pediatric headache emergency management are presented.Case Presentation: A 12-year-old male patient with a complex medical and surgical history, including post-repair pulmonary valve stenosis, visited the pediatric ED for intractable and worsening left frontoparietal headache, refractory to ibuprofen, for 6 days. A physical examination revealed severe photophobia and restlessness secondary to severe head pain. Non-contrast brain computed tomography demonstrated two round, bilateral, parietal hypodense lesions with surrounding vasogenic edema. The lesions were consistent with abscesses on magnetic resonance imaging. Eventually, the patient underwent successful surgical abscess drainage and made a full recovery. The patient was lost to follow-up; therefore, no causative bacterial species was determined. CONCLUSION Managing pediatric headache in emergency settings requires a robust history and physical examination. Cerebral abscesses are an infrequent but fatal cause of pediatric headache and therefore should be considered among the differential diagnoses.
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Affiliation(s)
- Moshe Bengio
- Emergency Department, HCA Aventura Hospital and Medical Center, Aventura, USA
| | - Glenn Goodwin
- Emergency Department, HCA Aventura Hospital and Medical Center, Aventura, USA
| | - Abhishek Roka
- Emergency Department, HCA Aventura Hospital and Medical Center, Aventura, USA
| | - Michelle Marin
- Emergency Department, HCA Palms West Children's Hospital, Loxahatchee, USA
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Hauser Chatterjee J, Hartford EA, Law E, Barry D, Blume H. Sumatriptan as a First-Line Treatment for Headache in the Pediatric Emergency Department. Pediatr Neurol 2023; 142:68-75. [PMID: 36958085 DOI: 10.1016/j.pediatrneurol.2023.01.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Revised: 09/23/2022] [Accepted: 01/29/2023] [Indexed: 02/05/2023]
Abstract
BACKGROUND Headache is a common presenting condition for patients seen in the pediatric emergency department (ED). Intranasal (IN) sumatriptan is a well-tolerated and safe abortive treatment for migraine headache, but it is infrequently administered in pediatric EDs. In this study we characterize an ED migraine pathway that uses IN sumatriptan as a first-line treatment. METHODS We performed retrospective chart analysis from a single center, reviewing a cohort of patients treated on an ED migraine pathway between October 2016 and February 2020. We reviewed patient demographics, clinical characteristics, treatment patterns, change in pain scores, sumatriptan prescriptions at discharge, length of stay (LOS), ED charges, and unexpected return visits. RESULTS A total of 558 patients (aged six to 21 years, 66% female) were included in this study. Overall, the median pretreatment pain score was 7 (interquartile range [IQR]: 5 to 8) and the median post-treatment pain score was 2 (IQR: 0 to 4). Forty-eight percent of patients received IN sumatriptan in the ED, and 36% of those who received sumatriptan were prescribed oral sumatriptan at discharge. When intravenous (IV) access was obtained for headache management, this was associated with a significantly longer LOS and higher ED charges. CONCLUSIONS IN sumatriptan shows promise as a feasible and potentially effective first-line treatment for pediatric migraine in the ED that could reduce the need for IV therapies, shorten LOS, and lower ED charges. Further research is needed to determine the efficacy of IN sumatriptan relative to other common first-line therapies used to treat pediatric migraine in the ED.
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Affiliation(s)
- Jessica Hauser Chatterjee
- Division of Child Neurology, Department of Neurology, University of Washington School of Medicine and the Seattle Children's Research Institute, Center for Integrative Brain Research, Seattle, Washington.
| | - Emily A Hartford
- Department of Pediatric Emergency Medicine, University of Washington, Seattle Children's Hospital, Seattle, Washington
| | - Emily Law
- Department of Anesthesiology & Pain Medicine, University of Washington School of Medicine, Seattle, Washington; Center for Child Health, Behavior & Development, Seattle Children's Research Institute, Seattle, Washington
| | - Dwight Barry
- Clinical Analytics, Seattle Children's Hospital, Seattle, Washington
| | - Heidi Blume
- Division of Child Neurology, Department of Neurology, University of Washington School of Medicine and the Seattle Children's Research Institute, Center for Integrative Brain Research, Seattle, Washington
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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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Standardized Headache Therapy in the Pediatric Emergency Department Using Improvement Methodology. Pediatr Qual Saf 2021; 6:e443. [PMID: 34345756 PMCID: PMC8322484 DOI: 10.1097/pq9.0000000000000443] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Accepted: 02/16/2021] [Indexed: 11/25/2022] Open
Abstract
Supplemental Digital Content is available in the text. Introduction: Primary headache is a common cause of pediatric emergency department (PED) visits. Without published guidelines to direct treatment options, various strategies lacking evidence are often employed. This study aims to standardize primary headache treatment in the PED by promoting evidence-based therapies, reducing nonstandard abortive therapies, and introducing dihydroergotamine (DHE) into practice. Methods: A multidisciplinary team developed key drivers, created a clinical care algorithm, and updated electronic medical record order sets. Outcome measures included the percentage of patients receiving evidence-based therapies, nonstandard abortive therapies, DHE given after failed first-line therapies, and overall PED length of stay. Process measures included the percent of eligible patients with the order set usage and medications received within 90 minutes. Balancing measures included hospital admissions and returns to the PED within 72 hours. Annotated control charts depicted results over time. Results: We collected data from July 2017 to December 2019. The percent of patients receiving evidence-based therapies increased from 69% to 73%. The percent of patients receiving nonstandard abortive therapies decreased from 2.5% to 0.6%. The percent of patients receiving DHE after failed first-line therapies increased from 0% to 37.2%. No untoward effects on process or balancing measures occurred, with sustained improvement for 14 months. Conclusion: Standardization efforts for patients with primary headaches led to improved use of evidence-based therapies and reduced nonstandard abortive therapies. This methodology also led to improved DHE use for migraine headache resistant to first-line therapies. We accomplished these results without increasing length of stay, admission, or return visits.
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Abstract
PURPOSE OF REVIEW This article reviews treatment options for patients presenting with headache in the emergency department (ED) and for inpatients, including red flags and status migrainosus (SM). RECENT FINDINGS Most patients presenting with headache in the ED will have migraine, but red flags must be reviewed to rule out secondary headaches. SM refractory to home treatment is a common reason for ED presentation or inpatient admission, but high-quality treatment evidence is lacking. Common treatments include intravenous fluids, anti-dopaminergic agents with diphenhydramine, steroids, divalproex, nonsteroidal anti-inflammatory drugs, intravenous dihydroergotamine, and nerve blocks. Other therapies (e.g., ketamine and lidocaine) are used with limited or inconsistent evidence. There is evidence for inpatient behavioral management therapy. This article details red flags to review in the workup of headache presentation in the ED and provides a step-wise approach to ED and inpatient management. However, more studies are needed to better optimize care.
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Affiliation(s)
- Jennifer Robblee
- Jan and Tom Lewis Migraine Treatment Program, Department of Neurology, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ, USA.
| | - Kate W Grimsrud
- Cerebrovascular and Hospital Neurology, Penrose Neuroscience, Colorado Springs, CO, USA
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Skora CE, Worden LT, Oakley CB. Comprehensive Migraine Initiative in the Pediatric Emergency Department Improves Treatment Outcomes. J Child Neurol 2020; 35:235-241. [PMID: 31805806 DOI: 10.1177/0883073819889711] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
OBJECTIVE To compare pediatric migraine treatment efficacy in the emergency department before and after the implementation of a comprehensive migraine initiative, consisting of a standardized treatment protocol, provider educational series and standardized physician documentation template. BACKGROUND Pediatric migraine is common, accounting for 1% of pediatric emergency department visits. Yet there is large variability in treatment practices, with few studies looking into measures of both clinical effectiveness and timeliness of treatment following implementation of standardized protocols. METHODS A single-center retrospective chart review of pediatric patients presenting to the emergency department with migraine before and after implementation of an institutional headache initiative designed to more effectively and efficiently deliver care to pediatric migraine patients. RESULTS The study yielded 110 patients each in the intervention and preintervention groups. There were no significant differences in patient characteristics with respect to age, gender, or initial pain score. Compared with the preintervention group, the intervention group demonstrated a significant reduction in headache pain score prior to discharge (decrease of 5.9 vs 4.8 in preintervention group, P value .006) with a greater percentage of patients achieving ≥50% reduction in pain (82% vs 67% in preintervention group, P value .039). Additionally, we found a significantly decreased time to treatment in the intervention group compared with the preintervention group (1.8 vs 2.1 hours, P value .046). CONCLUSION Through the use of a standardized treatment protocol, improved provider education, and ease of documentation, this comprehensive migraine initiative improved efficacy and efficiency of migraine treatment in the pediatric emergency department.
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Affiliation(s)
- Clare E Skora
- Department of Pediatric Neurology, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Lila T Worden
- Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Chris B Oakley
- Department of Pediatric Neurology, Johns Hopkins Hospital, Baltimore, MD, USA
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Abstract
PURPOSE OF REVIEW The current article reviews recent data on treatment of acute headache patients in the acute care setting. RECENT FINDINGS Intravenous fluid hydration, a common component of emergency department (ED) migraine therapy, does not improve pain outcomes and leads to longer ED lengths of stay. Therefore, intravenous fluids should be administered only to migraine patients with clinical evidence of dehydration. Similarly, intravenous ketamine has garnered interest as a treatment for acute pain but does not provide substantial relief to migraine patients. New studies on the serotonin (5-HT3; 5-hydroxytryptamine-3) antagonist granisetron, intranasal lidocaine, and high-flow oxygen have reported conflicting results for migraine patients. Finally, although experts recommend avoiding opioids in migraine treatment, opioid administration remains prevalent in the ED. A new study has demonstrated that patients who receive intravenous hydromorphone in the ED are much less likely to attain acute headache relief. Standardized headache protocols may decrease opioid use and provide significant pain relief for patients. SUMMARY Recent data have clarified the role of opioids and ketamine in the ED (do not use!). The role of treatment protocols and intravenous fluids is still ill-defined. Subpopulations of migraine patients may benefit from high-flow oxygen and intranasal lidocaine.
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Rastogi RG, Borrero-Mejias C, Hickman C, Lewis KS, Little R. Management of Episodic Migraine in Children and Adolescents: a Practical Approach. Curr Neurol Neurosci Rep 2018; 18:103. [DOI: 10.1007/s11910-018-0900-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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Marzuillo P, Calligaris L, Amoroso S, Barbi E. Narrative review shows that the short-term use of ketorolac is safe and effective in the management of moderate-to-severe pain in children. Acta Paediatr 2018; 107:560-567. [PMID: 29247538 DOI: 10.1111/apa.14189] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2017] [Revised: 10/30/2017] [Accepted: 12/07/2017] [Indexed: 11/26/2022]
Abstract
In June 2013, the European Medicine Agency recommended limiting codeine use in paediatric patients, creating a void in managing moderate pain. We reviewed the literature published in English (1985-June 2017) on the pharmacokinetic, pharmacodynamic and safety profile of ketorolac, a possible substitute for codeine and opioids, for treating moderate-to-severe pain. We found that gastrointestinal side effects were mainly reported with prolonged use, significant bleeding was reported in adenotonsillectomy, and adverse renal effects appeared to be limited to patients with specific coexisting risk factors. CONCLUSION The short-term use of ketorolac appears to be safe for children in many situations.
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Affiliation(s)
- Pierluigi Marzuillo
- M.D. Department of Women and Children and General and Specialized Surgery; Università degli studi della Campania “Luigi Vanvitelli”; Naples Italy
| | - Lorenzo Calligaris
- M.D. Institute for Maternal and Child Health IRCCS “Burlo Garofolo”; Trieste Italy
| | | | - Egidio Barbi
- M.D. Institute for Maternal and Child Health IRCCS “Burlo Garofolo”; Trieste Italy
- University of Trieste; Trieste Italy
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Little RD. Emergency Department Evaluation and Management of Children With Headaches. CLINICAL PEDIATRIC EMERGENCY MEDICINE 2017. [DOI: 10.1016/j.cpem.2017.09.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Faber AJ, Lagman-Bartolome AM, Rajapakse T. Drugs for the acute treatment of migraine in children and adolescents. Paediatr Child Health 2017; 22:454-458. [PMID: 29479263 DOI: 10.1093/pch/pxx170] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Affiliation(s)
| | | | - Thilinie Rajapakse
- Alberta Children's Hospital, Cumming School of Medicine, University of Calgary, Calgary, Alberta
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