Treatment of children with migraine in the emergency department: a qualitative systematic review

Disparities and Trends in Migraine Management in Pediatric Emergency Departments, 2009-19

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.

A randomized controlled pilot study of intranasal lidocaine in acute management of paediatric migraine and migraine-like headache

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.

Mapping the evidence and gaps of interventions for pediatric chronic pain to inform policy, research, and practice: A systematic review and quality assessment of systematic reviews

Background: Reviews in pediatric chronic pain often focus on only one intervention or population, making it difficult for policymakers and decision makers to quickly synthesize knowledge to inform larger-scale policy and funding priorities. Aims: The aims of this study were to (1) create an evidence and gap map of interventions for pediatric chronic pain and (2) identify gaps between existing evidence and recently identified patient-oriented research priorities. Methods: We performed a systematic review of English-language peer-reviewed systematic reviews or clinical practice guidelines of pediatric chronic pain intervention published in the past 20 years. Database searches of Medline, Embase, PsycINFO, Web of Science, CINAHL, and SCOPUS were conducted inclusive to June 3, 2019. Review quality was assessed using the AMSTAR-2. Results: Of 4168 unique abstracts, 50 systematic reviews (including 2 clinical practice guidelines) crossing diverse pediatric chronic pain populations and intervention settings were included. One third were rated high quality, with half rated low to critically low quality. The largest proportion of reviews addressed psychological and pharmacological interventions, followed by interdisciplinary, other (e.g., dietary), and physical interventions. Most common outcomes included pain, physical, emotional, and role functioning and quality of life. Treatment satisfaction and adverse events were less common, with minimal report of sleep or economic factors. Most patient-oriented research priorities had not been investigated. Conclusions: Sufficient quality evidence is available to guide evidence-informed policies in pediatric chronic pain, most notably regarding psychological and pharmacological interventions. Numerous evidence gaps in patient-oriented research priorities and treatment outcomes should guide prioritization of research funds, as well as study aims and design.

Emergency Department and Inpatient Management of Headache in Adults

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.

Psychosocial and Demographic Characteristics of Children and Adolescents With Headache Presenting for Treatment in a Headache Infusion Center

BACKGROUND

Approximately 10% of pediatric patients have recurrent headaches, with migraine being the most common headache type. If untreated, migraine may progress to status migrainosus, a debilitating condition of prolonged duration, high pain severity, and significant disability. There is high variability in the treatment of status migrainosus including medications used and treatment setting, which may occur in the emergency room, as an inpatient admission, or, less often, in an outpatient infusion center. The paucity of research on the treatment of status migrainosus is a limitation to treatment effectiveness.

OBJECTIVE

The objective of the study was twofold. First, we sought to examine the demographic characteristics of children and adolescents accessing our outpatient infusion center for prolonged headache. Second, we sought to determine whether any demographic or psychosocial differences exist between patients who access infusion therapy compared to patients who do not access infusion therapy for their headaches.

METHODS

We conducted a retrospective chart review of all patients between the ages of 6 and 19 years who were treated in our outpatient headache infusion center. A subset of these patients completed a behavioral health evaluation (treatment group) and they were compared to a control group of similar age (birthdate within 6 months) and gender to patients not seeking infusion treatment. Variables of interest included patient demographics, headache type and characteristics, and scores on the Pediatric Quality of Life Inventory (PedsQL), Functional Disability Inventory (FDI), Pediatric Pain Coping Inventory (PPCI), and the Behavior Assessment System for Children - Second Edition (BASC-2).

RESULTS

A total of 284 patients were included in the study (n = 227 receiving infusion treatment and n = 57 controls). Patients were primarily female (224/286; 78.9%), Caucasian (254/286; 90.1%), and had a mean age of 15 years. Findings suggest a promising difference in the PPCI Distraction subscale, χ² (1) = 3.7, P = .054, with a mean rank score of 61.90 for the treatment group and 50.21 for the control group. Additionally, a statistically significant difference was noted on the Social Support subscale, χ² (1) = 10.6, P = .001, with a mean rank score of 65.92 for the treatment group and 46.26 for the control group. Results also indicated a statistically significant difference in disability scores, χ² (1) = 10.0, P = .002, with a mean rank FDI score of 66.83 for the treatment group and 47.34 for the control group. Patients in the infusion group also reported lower quality of life on the PedsQL Total score (F[1, 109] = 5.0, P = .028; partial η²  = 0.044), and on the Physical (F[1, 109] = 7.9, P = .006; partial η²  = 0.069) and School (F[1, 109] = 4.6, P = .035; partial η²  = 0.041) subscales. No significant differences were found on the BASC-2. Parent reported data also revealed a significantly higher level of disability among patients seeking infusion treatment compared to the non-infusion group χ² (1) = 11.7, P = .001. However, there were no significant differences on the PedsQL, PPCI, or BASC-2.

CONCLUSIONS

Our findings support the disabling nature of migraine among children and adolescents, with higher levels of disability and lower quality of life reported in the group of patients utilizing infusion treatment. Developing concrete treatment plans and goals combined with bio-behavioral therapy are necessary to reduce functional disability and increase quality of life among these patients. Awareness of this patient group's pain-related coping strategies may help health care providers tailor treatment recommendations and develop or refine cognitive-behavioral headache treatment techniques.

Treatment of acute migraine attacks in children with analgesics on the World Health Organization Essential Medicines List: A systematic review and GRADE evidence synthesis

Background The World Health Organization Essential Medicines List (WHO EML) contains two analgesics for treatment of acute migraine attacks in children, ibuprofen and paracetamol. Methods The Embase, CDSR, CENTRAL, DARE and MEDLINE databases were searched up to 18 April 2017. We analyzed randomized controlled trials (RCTs) and systematic reviews (SRs) that investigate the efficacy and safety of ibuprofen or paracetamol for treatment of acute migraine attacks in children. We conducted meta-analysis and assessments of evidence with GRADE, Cochrane risk of bias tool, and AMSTAR. Results Three RCTs (201 children) and 10 SRs on ibuprofen and/or paracetamol for acute migraine attacks in children were included. Meta-analysis indicated that ibuprofen was superior to placebo for pain-free at 2 h or pain relief at 2 h, without difference in adverse events. There were no differences between paracetamol and placebo, or ibuprofen and paracetamol. Ten SRs that analyzed various therapies for migraine in children were published between 2004 and 2016, with discordant conclusions. Conclusion Limited data from poor quality RCTs indicate that ibuprofen and paracetamol might be effective analgesics for treating migraine attacks in children. Inclusion of ibuprofen and paracetamol as antimigraine medicines for children in the WHO EML is supported by indirect evidence from studies in adults.

Managing Pediatric Pain in the Emergency Department

Far more attention is now given to pain management in children in the emergency department (ED). When a child arrives, pain must be recognized and evaluated using a pain scale that is appropriate to the child's development and regularly assessed to determine whether the pain intervention was effective. At triage, both analgesics and non-pharmacological strategies, such as distraction, immobilization, and dressing should be started. For mild pain, oral ibuprofen can be administered if the child has not received it at home, whereas ibuprofen and paracetamol are suitable for moderate pain. For patients who still require pain relief, oral opioids could be considered; however, many EDs have now replaced this with intranasal fentanyl, which allows faster onset of pain relief and can be administered on arrival pending either intravenous access or definitive care. Intravenous opioids are often required for severe pain, and paracetamol or ibuprofen can still be considered for their likely opioid-sparing effects. Specific treatment should be used for patients with migraine. In children requiring intravenous access or venipuncture, non-pharmacological and pharmacological strategies to decrease pain and anxiety associated with needle punctures are mandatory. These strategies can also be used for laceration repairs and other painful procedures. Despite the gaps in knowledge, pain should be treated with the most up-to-date evidence in children seen in EDs.

The Use of a Pediatric Migraine Practice Guideline in an Emergency Department Setting

OBJECTIVE

The aim of the study was to evaluate the safety and efficacy of a standardized pediatric migraine practice guideline in the emergency department (ED).

METHODS

Migraine Clinical Practice Guideline (MCPG) was created in collaboration with the Division of Pediatric Neurology and Pediatric Emergency Medicine. The MCPG was established on evidence-based data and best practice after a review of the literature. The MCPG was implemented for patients with a known diagnosis of migraine headaches and a verbal numeric pain score (VPS) greater than 6 on a 0 to 10 scale. Patients received intravenous saline, ketorolac, diphenhydramine, and either metoclopramide or prochlorperazine. After 40 minutes, another VPS was obtained, and if no improvement, a repeat dose of metoclopramide or prochlorperazine was administered. If after 40 minutes and minimal pain relief occurred, a consult to neurology was made. A chart review of patients enrolled in the MCPG from April 2004 to April 2013 was conducted. We recorded demographic data, vital signs, ED length of stay, initial VPS, last recorded VPS, adverse events, and admission rate. Nonparametric statistics were performed.

RESULTS

A total of 533 charts were identified with a discharge diagnosis of migraine headache of which 266 were enrolled in the MCPG (179 females and 87 males). Mean (SD) age was 13.9 (3.1). Mean (SD) initial VPS was 7.8 (2.0). Mean (SD) discharge VPS was 2.1 (2.8), representing a 73% reduction of pain. Twenty patients (7.5%) were admitted for status migrainosus; mean (SD) age was 14.0 (3.5) years and mean (SD) VPS was 6.3 (2.8). Mean (SD) length of stay in ED was 283 (107) minutes. No adverse events were identified.

CONCLUSIONS

Our MCPG was clinically safe and effective in treating children with acute migraine headaches. Our data add to the dearth of existing published literature on migraine treatment protocols in the ED setting. We recommend additional prospective and comparative studies to further evaluate the effectiveness of our protocol in this patient population.

Acute Treatment Regimens for Migraine in the ED

Researchers at Children's Hospital, Boston, studied the comparative effectiveness of acute medication regimens for the prevention of ED visits with migraine.

A comparison of acute treatment regimens for migraine in the emergency department

BACKGROUND AND OBJECTIVES

Migraine headache is a common pediatric complaint among emergency department (ED) patients. There are limited trials on abortive therapies in the ED. The objective of this study was to apply a comparative effectiveness approach to investigate acute medication regimens for the prevention of ED revisits.

METHODS

Retrospective study using administrative data (Pediatric Health Information System) from 35 pediatric EDs (2009-2012). Children aged 7 to 18 years with a principal diagnosis of migraine headache were studied. The primary outcome was a revisit to the ED within 3 days for discharged patients. The primary analysis compared the treatment regimens and individual medications on the risk for revisit.

RESULTS

The study identified 32,124 children with migraine; 27,317 (85%) were discharged, and 5.5% had a return ED visit within 3 days. At the index visit, the most common medications included nonopioid analgesics (66%), dopamine antagonists (50%), diphenhydramine (33%), and ondansetron (21%). Triptans and opiate medications were administered infrequently (3% each). Children receiving metoclopramide had a 31% increased odds for an ED revisit within 3 days compared with prochlorperazine. Diphenhydramine with dopamine antagonists was associated with 27% increased odds of an ED revisit compared with dopamine antagonists alone. Children receiving ondansetron had similar revisit rates to those receiving dopamine antagonists.

CONCLUSIONS

The majority of children with migraines are successfully discharged from the ED and only 1 in 18 required a revisit within 3 days. Prochlorperazine appears to be superior to metoclopramide in preventing a revisit, and diphenhydramine use is associated with increased rates of return.

Pediatric migraine prescription patterns at a large academic hospital

BACKGROUND

Here we report the prescription patterns by drug type, age, and sex of patients at a large academic pediatric hospital. Because there are few guidelines based on outcome studies in pediatric migraine, physician treatment approaches in children vary.

METHODS

Using the i2b2 query tool, we determined that over an approximately 4 year period, 4839 patients between the ages of 2 and 17 years were observed at Boston Children's Hospital for migraine with or without aura, 59% women and 41% men.

RESULTS

The most common medications prescribed to this population were sumatriptan, amitriptyline, topiramate, ondansetron, and cyproheptadine.

CONCLUSIONS

Our findings support recent data regarding choices of medication in the pediatric population and additionally support current studies and future investigation into controlled trials in the pediatric population.

Evaluation and treatment of migraine in the emergency department: a review

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.

Pediatric headache: where have we been and where do we need to be

In this article, we hope to summarize current understanding of pediatric headache. We discuss epidemiology, genetics, classification, diagnosis, outpatient, emergency and inpatient treatment options, prevention strategies, and behavioral approaches. For each section, we end with a series of questions for future research and consideration.

Effectiveness of standardized combination therapy for migraine treatment in the pediatric emergency department

OBJECTIVE

To compare outcomes of pediatric migraine patients treated in an emergency department (ED) before and after implementation of a standardized combination intravenous therapy regimen aimed toward improving and standardizing abortive migraine therapy.

BACKGROUND

In a pediatric ED, migraines represent 8-18% of all headache visits. Despite this large number, no standard treatment for acute migraine therapy currently exists.

METHODS

The study utilized a retrospective chart review of patients seeking acute migraine treatment at a tertiary care, pediatric ED from August 2006 to March 2010. Inclusion criteria were pediatric migraine patients as defined by International Headache Society guidelines. The comparison population received various migraine therapies based on attending practice preference. After October 2008, patients received standardized intravenous combination therapy involving a normal saline fluid bolus, ketorolac, prochlorperazine, and diphenhydramine. Occasionally, metoclopramide was substituted during prochlorperazine shortages. Reduction in headache pain score was the primary outcome. Secondary outcome measures included length of ED stay, hospital admission rate, and ED readmission rate within 48 hours.

RESULTS

The study yielded 87 patients who received standardized combination therapy and 165 comparison patients. No significant difference in patient characteristics existed when evaluating patient demographics, outpatient medication use, and initial headache pain score. When compared with the non-standardized therapy population, the combination therapy patients revealed significant reductions in pain score (decrease of 5.3 vs. 6.9, difference -1.6, 95% confidence interval -2.2 to -0.8, P < .001), length of ED stay (5.3 vs. 4.4 hours, difference 0.9, 95% confidence interval 0.2-1.6, P = .008), and hospital admission rate (32% vs. 3%, P < .001) without changes in ED return rate (7% vs. 2%, P = .148).

CONCLUSION

Standardized combination therapy is effective for acute pediatric migraine therapy in the ED by significantly reducing headache pain scores, length of ED stay, and hospital admission rates.

Treatment of pediatric status migrainosus: can we prevent the "bounce back"?

The impact of treatment given upon discharge on the "bounce back" rate was ascertained in children presenting at the emergency department for treatment of status migrainosus. All children ages 8 to 17 years old presenting to an emergency department in 2008 who were treated for status migrainosus and discharged home were included. Of the total of 187 patients, 21 patients (11.2%) bounced back. Treatment given was not associated with the bounce back rate. The only factors reaching significance were the presence of a migraine equivalent in 28.6% of patients who bounced back as compared with only 6.7% in patients without recurrence (P = .006); brain imaging study in the emergency department (52.4% vs. 16.9%, P = .001); and an arranged physician follow-up (66.6% vs. 36.3%, P = .01). The results appear to suggest that no current treatment given to children presenting to the emergency department with status migrainosus seems to alter the immediate recurrence rate.

Prochlorperazine in children with migraine: a look at its effectiveness and rate of akathisia

OBJECTIVE

The objective of this study is to evaluate the effectiveness of prochlorperazine and the rate of akathisia in children with severe migraine.

METHODS

The study is a prospective cohort of a convenient sample of patients younger than 18 years old diagnosed with migraine and treated with intravenous prochlorperazine in adjunction with diphenhydramine in the emergency department. The evaluation of pain and akathisia was performed before the treatment and was repeated 60 minutes later and before discharge. A telephone follow-up was completed to assess relapse in pain and presence of akathisia. The effectiveness of prochlorperazine was determined using different outcomes: 50% reduction of pain, pain-free patients, treatment failure, and relapse of pain.

RESULTS

Of the 79 patients included in the study for 25 months, 64 (81%) either met the International Headache Society criteria or had a diagnosis of migraine confirmed by a neurologist at follow-up. Among these patients, 47 (100%) of 47 had a 50% reduction of pain, and 24 (50%) of 48 were pain free at discharge. Only 14 (22%) of 64 patients had a treatment failure. However, 43 (68%) of 63 patients had a relapse of their headache within the first week after discharge. Overall, among the 79 patients, 4 (5%) had a definitive diagnosis of akathisia, but 27 (34%) other patients presented symptoms suggesting a possible diagnosis of akathisia.

CONCLUSION

Prochlorperazine seems very effective to decrease pain on a short-term basis in children. However, more than two thirds of the patients, overall, had a relapse of their migraine at home in the first week. Despite the use of diphenhydramine, akathisia remains a concern.

Overview of diagnosis and management of paediatric headache. Part II: therapeutic management

A thorough evaluation of headache in children and adolescents is necessary to make the correct diagnosis and initiate treatment. In part 1 of this article (Özge et al. in J Headache Pain, 2010), we reviewed the diagnosis of headache in children and adolescents. In the present part, we will discuss therapeutic management of primary headaches. An appropriate management requires an individually tailored strategy giving due consideration to both non-pharmacological and pharmacological measures. Non-pharmacological treatments include relaxation training, biofeedback training, cognitive-behavioural therapy, different psychotherapeutic approaches or combinations of these treatments. The data supporting the effectiveness of these therapies are less clear-cut in children than in adults, but that is also true for the data supporting medical treatment. Management of migraine and TTH should include strategies relating to daily living activities, family relationships, school, friends and leisure time activities. In the pharmacological treatment age and gender of children, headache diagnosis, comorbidities and side effects of medication must be considered. The goal of symptomatic treatment should be a quick response with return to normal activity and without relapse. The drug should be taken as early as possible and in the appropriate dosage. Supplementary measures such as rest in a quiet, darkened room is recommended. Pharmaco-prophylaxis is only indicated if lifestyle modification and non-pharmacological prophylaxis alone are not effective. Although many prophylactic medications have been tried in paediatric migraine, there are only a few medications that have been studied in controlled trials. Multidisciplinary treatment is an effective strategy for children and adolescents with improvement of multiple outcome variants including frequency and severity of headache and school days missed because of headache. As a growing problem both children and families should be informed about medication overuse and the children's drug-taking should be checked.

Management of chronic daily headache in children

Children and adolescents can develop frequent, at times daily, headaches. The more severe forms of headaches that these children experience are often migrainous. This article discusses the typical characteristics of these patients and reviews treatments considered in this condition. Unfortunately, there are no high-quality studies to definitively guide treatment in children with chronic daily headache. Treatment decisions are often made using data from adult studies, childhood studies on episodic migraine or expert opinion. Current data on which to base treatment decisions are reviewed in this article.

Do pediatric headaches respond to bilateral lower cervical paraspinous bupivacaine injections?

OBJECTIVE

Bilateral lower cervical paraspinous intramuscular bupivacaine injections have recently been reported as a therapeutic modality for headache pain in adult patients presenting to an emergency department. In this study, we accomplished a retrospective review of all pediatric patients with headaches who were treated with this technique in an emergency department setting over a 16-month period. The therapeutic response of all pediatric patients who received bilateral lower cervical paraspinous intramuscular bupivacaine injections for headache pain is described in this article.

METHODS

Three separate databases were reviewed to capture all patients younger than 18 years with a diagnosis of headache who received bilateral cervical injections between June 30, 2003, and December 1, 2004, in the Medical College of Georgia and Children's Medical Center emergency departments. Their medical records were retrospectively reviewed to determine their response to this procedure.

RESULTS

The headaches of 13 patients younger than 18 years were treated with this procedure. The mean headache severity was 9.15, and the mean duration of headache was 3.16 days. Six (46.2%) of 13 patients had complete relief of their headaches, whereas 5 (38.4%) of 13 patients had partial relief. No significant relief was documented in 2 (15.4%) of 13 patients. A therapeutic response was documented in 11 (84.6%) of 13 of the patients.

CONCLUSIONS

These retrospective observations suggest that bilateral lower cervical paraspinous intramuscular injections with small amounts of bupivacaine may have a therapeutic role in the management of headache pain in children, and their rate of therapeutic response may be similar to that recently reported for adult headache patients.