Tolerability and effectiveness of prochlorperazine for intractable migraine in children

International Headache Society global practice recommendations for the acute pharmacological treatment of migraine

BACKGROUND

In an effort to improve migraine management around the world, the International Headache Society (IHS) has here developed a list of practical recommendations for the acute pharmacological treatment of migraine. The recommendations are categorized into optimal and essential, in order to provide treatment options for all possible settings, including those with limited access to migraine medications.

METHODS

An IHS steering committee developed a list of clinical questions based on practical issues in the management of migraine. A selected group of international senior and junior headache experts developed the recommendations, following expert consensus and the review of available national and international headache guidelines and guidance documents. Following the initial search, a bibliography of twenty-one national and international guidelines was created and reviewed by the working group.

RESULTS

A total of seventeen questions addressing different aspects of acute migraine treatment have been outlined. For each of them we provide an optimal recommendation, to be used whenever possible, and an essential recommendation to be used when the optimal level cannot be attained.

CONCLUSION

Adoption of these international recommendations will improve the quality of acute migraine treatment around the world, even where pharmacological options remain limited.

Clinical characterization of pediatric acute confusional migraine: a single-center case series

INTRODUCTION

Acute confusional migraine (ACM) is a rare disorder characteristic of pediatric patients. Our objective was to describe the clinical characteristics of patients diagnosed with ACM who visited our pediatric emergency department (PED).

METHODS

This study was a retrospective review of children who presented to our PED between January 2012 and December 2022 with a discharge diagnosis of ACM.

RESULTS

During the study period, 23 patients were enrolled: 11 males (47.8%) and 12 females (52.2%); median age was 10.8 years (IQR: 8.3-13.6). Eight patients reported a history of headache. The median length of stay of PED was 4.7 h. Onset was abrupt (less than 12 h) in 100% of cases. Changes in the level and content of consciousness occurred in 47.8% and 91.3% of patients, respectively; confusion (73.9%) was the most common neurological manifestation. Eighteen patients had urgent brain CT scans, none showing pathological findings. Four patients required benzodiazepines to control their psychomotor agitation. Nine patients were hospitalized, including one in the intensive care unit. Two patients underwent MRI and one patient underwent EEG during hospitalization, with normal results.

DISCUSSION

ACM is a rare condition in pediatric neurology characterized by acute onset of confusion or altered mental status before, during, or after migraine headache. Clinical features overlap with other neurological disorders, making diagnosis challenging. To improve the diagnosis, treatment, and research of AMC, it is essential to include it in the International Classification of Headache Disorders and establish standardized diagnostic criteria.

Intranasal ketorolac versus intravenous ketorolac for treatment of migraine headaches in children: A randomized clinical trial

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.

Efficacy of outpatient infusion therapy in pediatric patients with postconcussive headaches

PURPOSE

To determine the relative efficacy of intravenous therapy for postconcussive headaches in a pediatric population, as compared to oral therapy.

METHODS

Pediatric patients treated for postconcussive headaches at an outpatient infusion clinic from 2016 to 2018 were selected for inclusion in the study. Of the 95 patients who were treated in clinic, 53 patients were selected for a retrospective chart review. Clinic visits before and after infusions were reviewed to determine changes in headache score (HA), symptom severity score (SSS), and self-reported symptom relief. An age-matched and SSS-matched group served as a control. The control group received only oral therapy for their headaches. The infusion consisted of parenteral ketorolac, compazine, diphenhydramine, and a normal saline bolus (20 mg/kg).

RESULTS

Following infusion therapy, overall mean HA and SSS scores were both reduced (p < 0.0001). Oral therapy demonstrated a similar mean overall reduction in HA and SS scores (p < 0.0001). While both groups achieved a reduction in HA and SS scores, there was not a statistically significant difference in reduction of symptoms scores between the oral and infusion groups.

CONCLUSION

Infusion therapy is as effective at reducing HA and SSS as established oral therapies. Infusion therapy may have a shorter time to headache abortion than oral therapy based on pharmacokinetics. Further, some physicians are unwilling to allow an athlete to return to play while taking suppressive medication. Future studies may show that an infusion could allow a more rapid return to play and resolution of symptoms.

Standardized Headache Therapy in the Pediatric Emergency Department Using Improvement Methodology

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.

Ondansetron for Acute Migraine in the Pediatric Emergency Department

BACKGROUND

Migraine patients are commonly encountered in the pediatric emergency departments. Much of the research on migraine treatment regimens involves antidopaminergic antiemetics such as prochlorperazine and metoclopramide. Despite a comparably more favorable side effect profile, no migraine treatment research has included ondansetron, a selective type three 5-hydroxytryptamine receptor antagonist. Our primary objective was to determine if treatment regimens including ondansetron were successful in reducing verbal pain scores.

METHODS

We retrospectively reviewed patients with migraine aged seven to 18 years who visited the pediatric emergency departments over a four-year period. Charts were reviewed for initial and discharge pain scores, pediatric emergency department revisits, neurology consultation, and opioid administration. The primary outcome was treatment success, defined as reduction in the verbal pain score of 50% or more. Secondary outcomes included adverse effects, receiving non-evidence-based treatment defined as receiving an opioid, neurology consultation rate, and pediatric emergency department revisit rate within 48 hours.

RESULTS

Ninety-eight encounters were included: 42 received ondansetron, 22 received an antidopaminergic, and 34 received no antiemetic. Thirty-eight patients (90%) in the ondansetron group (95% confidence interval 81 to 99) reached treatment success. Pediatric emergency department revisits, opioid administration, neurology consultation, and treatment success were similar among the ondansetron and antidopaminergic groups.

CONCLUSION

Ondansetron may be a useful medication in the treatment regimen of migraine patients in the pediatric emergency department. Preliminary data suggest that ondansetron is comparable to antidopaminergic agents.

Practice guideline update summary: Acute treatment of migraine in children and adolescents

Objective

To provide evidence-based recommendations for the acute symptomatic treatment of children and adolescents with migraine.

Methods

We performed a systematic review of the literature and rated risk of bias of included studies according to the American Academy of Neurology classification of evidence criteria. A multidisciplinary panel developed practice recommendations, integrating findings from the systematic review and following an Institute of Medicine–compliant process to ensure transparency and patient engagement. Recommendations were supported by structured rationales, integrating evidence from the systematic review, related evidence, principles of care, and inferences from evidence.

Results

There is evidence to support the efficacy of the use of ibuprofen, acetaminophen (in children and adolescents), and triptans (mainly in adolescents) for the relief of migraine pain, although confidence in the evidence varies between agents. There is high confidence that adolescents receiving oral sumatriptan/naproxen and zolmitriptan nasal spray are more likely to be headache-free at 2 hours than those receiving placebo. No acute treatments were effective for migraine-related nausea or vomiting; some triptans were effective for migraine-related phonophobia and photophobia.

Recommendations

Recommendations for the treatment of acute migraine in children and adolescents focus on the importance of early treatment, choosing the route of administration best suited to the characteristics of the individual migraine attack, and providing counseling on lifestyle factors that can exacerbate migraine, including trigger avoidance and medication overuse.

Migraine in children: presentation, disability and response to treatment

PURPOSE OF REVIEW

The current review presents findings from investigations of migraine in children. The presentation of pediatric migraine, related consequences, and medication treatments are reviewed.

RECENT FINDINGS

A number of advancements have been made in the study of the presentation, disability, and treatments for migraine in children. However, recent research suggests that not all approaches are equally effective in the treatment of migraine in children. Specifically, a recent study comparing pharmacological interventions found that preventive medications were not statistically more effective than placebo in children. Consistent findings showing clinically meaningful placebo response rates, shorter duration of headaches and other characteristic features (e.g. frontal, bilateral location) have been barriers to the design of randomized clinical trials in children and adolescents with migraine. Better understanding of treatment mechanisms for medication interventions is needed.

SUMMARY

Several migraine treatments have determined to be effective for use in children but few controlled studies have evaluated the effectiveness of medication treatments. Recent research suggests that preventive medications may not be more effective than placebo. Additional research is needed to evaluate the effectiveness of medication treatment in migraine headache care.

The Safety of Prochlorperazine in Children: A Systematic Review and Meta-Analysis

INTRODUCTION

Prochlorperazine is recommended for adults with breakthrough or refractory chemotherapy-induced nausea and vomiting (CINV). The objective of this review was to describe its safety in children when given for any indication to help define its role for CINV control in children.

METHODS

Electronic searches of MEDLINE, EMBASE, PsycINFO, and the Cochrane Central Register of Controlled Trials were performed as of 9 March 2015. All studies in English reporting adverse effects (AEs) associated with prochlorperazine in children (≤18 years) were included. AEs were synthesized for prospective studies.

RESULTS

Forty-nine (15 prospective) studies evaluating the use of prochlorperazine in 758 children were included. The most commonly reported AEs in prospective studies of prochlorperazine in children were sedation (multiple-dose studies: 10 %, 95 % CI 5-21) and extrapyramidal symptoms (EPS) (single-dose studies: 9 %, 95 % CI 3-29; multiple-dose studies: 4 %, 95 % CI 1-11). Serious AEs (seizure, neuroleptic malignant syndrome, autonomic collapse, tardive dyskinesia) were rarely associated with prochlorperazine use in children. Five fatalities were reported in children receiving prochlorperazine.

LIMITATIONS

The limitations of this systematic review and meta-analysis were that the AEs reported in the included studies were heterogeneous, the prospective use of systematic clinical tools to identify AEs was rare, and the risk of bias in most prospective studies was moderate.

CONCLUSIONS

The most common AEs reported with the pediatric use of prochlorperazine are EPS and sedation. Fatalities, life-threatening, and persistent AEs have also been reported.

Pediatric Headache and Seizures

Headache and seizures are two of the most common complaints seen in the field of pediatric neurology with headache being number one. Both these conditions may coexist. Where the difficulty begins is when the symptoms are not clear cut in making a diagnosis, and conditions are possible as either an atypical seizure or migraine variant. What further complicates matters is the fact that there are many underlying neurologic conditions that carry with them a higher likelihood of developing both headaches and seizures, making each a distinct possibility when obtaining a history from a parent about unusual spells. Although differentiating between seizure and headache may not be easy, with a focused yet thorough history and appropriate use of investigative tools, it can be done. Coming to the correct diagnosis is only the start; once seizures and or headaches have been appropriately diagnosed then the real challenge begins and that is finding a way to successfully treat the headaches and seizures. Within pediatric neurology, the acute options tend to be more diagnosis specific whereas the prophylactic ones may overlap and treat both headaches and seizures. In the following review, we will discuss the epidemiology of pediatric headaches and seizures, the overlap between these 2 conditions in diagnosis, as well as how to tell them apart, and the treatment options and prognosis of both common neurologic disorders in children.

Acute Treatment Therapies for Pediatric Migraine: A Qualitative Systematic Review

OBJECTIVE

We sought to conduct a qualitative systematic review to evaluate the safety and efficacy of available treatments for pediatric patients with migraine or benign primary headache in the emergency department, in an effort to inform future practice.

METHODS

Scopus, Medline, and PubMed databases were searched for randomized controlled trials retrospective reviews, review articles, and case studies discussing migraine or benign primary headache management that were conducted in the emergency room or outpatient acute care setting in pediatric patients (less than 18-years old). Meeting abstracts and cited references within articles were also evaluated. Multiple variables were recorded, including type of treatment, study design, dosing, primary outcome, and side effects. Therapeutic gain was calculated in studies with a placebo arm. Treatments were subjectively assessed based on methodology and number of trials for a particular therapy.

RESULTS

Thirty-one studies were included in the final analysis. Of these, 17 were randomized controlled trials, 9 were retrospective reviews, and 5 were prospective chart review studies. One pertained to IV fluids, 2 to nonspecific analgesic use, 5 to dopamine receptor antagonists, 2 to valproic acid, 1 to propofol, 1 to magnesium, 1 to bupivicaine, 13 to triptan medications, and 3 to dihydroergotamine (DHE). Treatments considered effective for acute migraine or benign primary headache in the analgesic category include ibuprofen, and to a lesser degree acetaminophen. Ketorolac was not compared to other NSAIDs, but was found to be less effective than prochlorperazine. Of the phenothiazines, prochlorperazine was considered most effective. Of the triptan medications, almotriptan, rizatriptan, zolmitriptan nasal spray, sumatriptan nasal spray, and combination sumatriptan/naproxen are effective agents for acute treatment. Treatments considered probably effective included IV fluids, chlorpromazine, valproate sodium, injectable sumatriptan, and IV DHE. Treatments with oral zolmitriptan showed inconsistent results, while treatments considered ineffective included isolated oral sumatriptan and oral DHE. There is insufficient evidence to comment on propofol, magnesium, and bupivicaine efficacy.

CONCLUSIONS

Of the available evidence, ibuprofen, prochlorperazine, and certain triptan medications are the most effective and safe agents for acute management of migraine and other benign headache disorders in the pediatric population. Additional studies in this population are needed, and should take into consideration variables such as dosing, co-administered medications, treatment duration, and length of treatment effect.

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.

Management of Primary Headache in the Emergency Department and Inpatient Headache Unit

Migraine is a chronic disorder with debilitating exacerbations throughout the lifetime of migraineurs. Children and adolescents are significantly affected. The prevalence of migraine in this age group is higher than predicted in the last decade. Fortunately, this chronic disease is getting more attention and recognition, and better treatments are now being offered to these patients. Different medications are available, mostly for the outpatient management of an attack and include the use of over-the-counter anti-inflammatory medications as well as prescribed medications like the triptans group. These therapies do sometime fail and the exacerbations can last days to weeks. Early aggressive intravenous treatment can be very effective in breaking the attack and allowing the child to be functional faster and sometimes may prevent chronification of an attack.

The optimal management of headaches in children and adolescents

The recognition of the diagnosis of migraine in children is increasing. Early and aggressive treatment of migraine in this population with the use of over-the-counter medications has proven effective. The off-label use of many migraine-specific medications is often accepted in the absence of sufficient evidenced-based trials. Mild to severe cases of migraine should be treated with nonsteroidal anti-inflammatory drugs, with triptans used in moderate to severe headaches unresponsive to over-the-counter therapy. Rescue medication including dihydroergotamine [DHE] should be used for status migrainosus, preferably in the hospital setting. Antiemetics that have antidopaminergic properties can be helpful in patients with associated symptoms of nausea and vomiting through their action on central migraine generation. Furthermore, patients and families should be educated on nonpharmacologic management such as lifestyle modification and avoidance of triggers that can prevent episodic migraine.

Management of Pediatric Migraine Headache in the Emergency Room and Infusion Center

Migraine is a common disorder that starts at an early age and takes a variable pattern from intermittent to chronic headache with several exacerbations throughout a lifetime. Children and adolescents are significantly affected. If an acute headache is not aborted by outpatient migraine therapy, it often causes severe disability, preventing the child from attending school and social events. Treating the acute severe headache aggressively helps prevent prolonged disability as well as possible chronification. Multiple medications are available, mostly for the outpatient management of an attack and include the use of over-the-counter anti-inflammatory medications as well as prescribed medications in the triptan group. These therapies do sometime fail and the exacerbation can last from days to weeks. If the headache lasts 72 hours or longer it will fall in the category of status migrainosus. Status migrainosus is described as a severe disabling headache lasting 72 hours or more by the ICHD3 criteria. Disability is a major issue in children and adolescents and aggressive acute measures are to be taken to control it as soon as possible. Early aggressive intravenous therapy can be very effective in breaking the attack and allowing the child to be quickly back to normal functioning. This article reviews what is available for the treatment of pediatric primary headaches in the emergency room.

Part II--Management of pediatric post-traumatic headaches

BACKGROUND

Post-traumatic headache is one of the most common symptoms occurring after mild traumatic brain injury in children.

METHODS

This is an expert opinion-based two-part review on pediatric post-traumatic headaches. In part II, we focus on the medical management of post-traumatic headaches. There are no randomized controlled trials evaluating the efficacy of therapies specifically for pediatric post-traumatic headaches. Thus, the algorithm we propose has been extrapolated from the primary headache literature and small noncontrolled trials of post-traumatic headache.

RESULTS

Most post-traumatic headaches are migraine or tension type, and standard medications for these headache types are used. A multifaceted approach is needed to address all the possible causes of headache and any comorbid conditions that may delay recovery or alter treatment choices. For acute treatment, nonsteroidal anti-inflammatories can be used. If the headaches have migrainous features and nonsteroidal anti-inflammatories are not effective, triptans may be beneficial. Opioids are not indicated. Medication overuse should be avoided. For preventive treatments, some reports indicate that amitriptyline, gabapentin, or topiramate may be beneficial. Amitriptyline is a good choice because it can be used to treat both migraine and tension-type headaches. Nerve blocks, nutraceuticals (e.g. melatonin), and behavioral therapies may also be useful, and lifestyle factors, especially adequate sleep hygiene and strategies to cope with anxiety, should be emphasized.

CONCLUSIONS

Improved treatment of acute post-traumatic headache may reduce the likelihood of developing chronic headaches, which can be especially problematic to effectively manage and can be functionally debilitating.

Inpatient management of migraine

Migraine is a frequently disabling disorder which may require inpatient treatment. Admission criteria for migraine include intractable migraine, nausea and/or vomiting, severe disability, and dependence on opioids or barbiturates. The inpatient treatment of migraine is based on observational studies and expert opinion rather than placebo-controlled trials. Well-established inpatient treatments for migraine include dihydroergotamine, neuroleptics/antiemetics, lidocaine, intravenous aspirin, and non-pharmacologic treatment such as cognitive-behavioral therapy. Short-acting treatments possibly associated with medication overuse, such as triptans, opioids, or barbiturate-containing compounds, are generally avoided. While the majority of persons with migraine are admitted on an emergency basis for only a few days, outcome studies and infusion protocols during elective admissions at tertiary headache centers suggest a longer length of stay may be needed for persons with intractable migraine.

Intravenous migraine therapy in children with posttraumatic headache in the ED

BACKGROUND

More than 3.8 million children sustain traumatic brain injuries annually. Treatment of posttraumatic headache (PTH) in the emergency department (ED) is variable, and benefits are unclear.

OBJECTIVE

The objective of the study is to determine if intravenous migraine therapy reduces pain scores in children with PTH and factors associated with improved response.

METHODS

This was a retrospective study of children, 8 to 21 years old, presenting to a tertiary pediatric ED with mild traumatic brain injury (mTBI) and PTH from November 2009 to June 2013. Inclusion criteria were mTBI (defined by diagnosis codes) within 14 days of ED visit, headache, and administration of one or more intravenous medications: ketorolac, prochlorperazine, metoclopramide, chlorpromazine, and ondansetron. Primary outcome was treatment success defined by greater than or equal to 50% pain score reduction during ED visit. Bivariate analysis and logistic regression were used to determine predictors of treatment success: age, sex, migraine or mTBI history, time since injury, ED head computed tomographic (CT) imaging, and pretreatment with oral analgesics.

RESULTS

A total of 254 patients were included. Mean age was 13.8 years, 51% were female, 80% were white, mean time since injury was 2 days, and 114 patients had negative head CTs. Eighty-six percent of patients had treatment success with 52% experiencing complete resolution of headache. Bivariate analysis showed that patients who had a head CT were less likely to respond (80% vs 91%; P = .008).

CONCLUSIONS

Intravenous migraine therapy reduces PTH pain scores for children presenting within 14 days after mTBI. Further prospective work is needed to determine long-term benefits of acute PTH treatment in the ED.

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.

Treatment of pediatric migraine

OPINION STATEMENT

The diagnosis of migraine in the pediatric population is increasing as providers are becoming more familiar with recognizing the condition. Over-the-counter and migraine-specific treatment, once considered off-label, have proven to be effective, especially if given at the early onset of head pain. Mild to severe cases of migraine should be treated with nonsteroidal anti-inflammatory drugs (NSAIDs), with triptans used alone or in combination in moderate to severe headaches unresponsive to over-the-counter therapy. Rescue medication including dihydroergotamine (DHE), a potent vasoconstrictor should be used for intractable migraines and is preferred in the hospital setting. Anti-emetics that have anti-dopaminergic properties can be helpful in patients with associated symptoms of nausea and vomiting along with headache, especially when used in combination therapy. Preventative treatment should be initiated early in patients with frequent headaches to improve headache outcomes and quality of life. Patients and families should be educated on non-pharmacologic management, such as lifestyle modification and avoidance of triggers, that can prevent progression and worsening of migraine.

Pediatric migraine: abortive management in the emergency department

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.

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 migraine in the emergency room

Migraine constitutes a relatively common reason for pediatric emergency room visits. Given the paucity of randomized trials involving pediatric migraineurs in the emergency department setting compared with adults, recommendations for managing these children are largely extrapolated from adult migraine emergency room studies and trials involving outpatient home pediatric migraine therapy. We review current knowledge about pediatric migraineurs presenting at the emergency room and their management, and summarize the best evidence available to guide clinical decision-making.

Treatment of acute migraine in the pediatric population

OPINION STATEMENT

The recognition of the diagnosis of migraine in the pediatric population is increasing. Early and aggressive treatment of migraine in children and adolescents with the use of over-the-counter medications has proven effective. In addition, the off-label use of many migraine-specific medications is often accepted in the absence of sufficient evidence-based trials. Mild to severe cases of migraine should be treated with NSAIDs, with triptans used for moderate to severe headaches that are unresponsive to over-the-counter therapy. Rescue medication including dihydroergotamine (DHE) should be used for intractable migraines, preferably in the hospital setting. In patients with associated symptoms of nausea and vomiting, antiemetics with antidopaminergic properties can be helpful through their action on central migraine generation. Furthermore, patients and families should be educated about nonpharmacologic aspects of management such as preventing episodic migraine through lifestyle modification and avoidance of triggers.

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.

Evaluation and management of children and adolescents presenting with an acute setting

Headache is the third leading cause of referral to a pediatric emergency room. It is imperative for providers to be able to rule out rare but possible life-threatening disorders, such as meningitis, intracranial hemorrhage, brain tumor, or hydrocephalus. Most of the presenting headaches are secondary to viral illnesses followed by primary headache and migraine. A detailed initial evaluation is essential to guide toward necessary testing as well as diagnosis.

A prospective, randomized trial of intravenous prochlorperazine versus subcutaneous sumatriptan in acute migraine therapy in the emergency department

STUDY OBJECTIVE

Intravenous (IV) prochlorperazine with diphenhydramine is superior to subcutaneous sumatriptan in the treatment of migraine patients presenting to the emergency department (ED).

METHODS

In this randomized, double-blind, placebo-controlled trial, after providing written informed consent, patients presenting to the ED with a chief complaint of migraine received a 500-mL bolus of IV saline solution and either 10 mg prochlorperazine with 12.5 mg diphenhydramine IV plus saline solution placebo subcutaneously or saline solution placebo IV plus 6 mg sumatriptan subcutaneously. Pain intensity was assessed with 100-mm visual analog scales (visual analog scale at baseline and every 20 minutes for 80 minutes). The primary outcome was change in pain intensity from baseline to 80 minutes or time of ED discharge if subjects remained in the ED for fewer than 80 minutes after treatment. Sedation and nausea were assessed every 20 minutes with visual analog scale scales, and subjects were contacted within 72 hours to assess headache recurrence.

RESULTS

Sixty-eight subjects entered the trial, with complete data for 66 subjects. Baseline pain scores were similar for the prochlorperazine/diphenhydramine and sumatriptan groups (76 versus 71 mm). Mean reductions in pain intensity at 80 minutes or time of ED discharge were 73 mm for the prochlorperazine/diphenhydramine group and 50 mm for those receiving sumatriptan (mean difference 23 mm; 95% confidence interval 11 to 36 mm). Sedation, nausea, and headache recurrence rates were similar.

CONCLUSION

IV prochlorperazine with diphenhydramine is superior to subcutaneous sumatriptan in the treatment of migraine.

Emergency department treatment of primary headaches in children and adolescents

PURPOSE OF REVIEW

Headaches in children and adolescents are common presenting complaints in emergency departments. There is wide variation among acute treatments. We sought to review options for acute emergency department management and the recent evidence supporting their use.

RECENT FINDINGS

Currently accepted diagnosis of pediatric headache is based on the International Classification of Headache Disorders-II classification system, which remains incomplete with regard to pediatric patients. In general, there is a paucity of studies evaluating acute treatment for pediatric headache, especially in the emergency department setting. Most studies use previously diagnosed patients with migraines as their subjects. Recent additions to the literature are mostly reviews in nature or pertain to the evaluation of triptan use in adolescents. No articles evaluate treatment of tension-type headaches.

SUMMARY

Further research is needed on therapies targeted toward children and adolescents with headache subtypes other than migraine, including those without a previous diagnosis. While little evidence exists, most authors agree with an initial trial of ibuprofen followed by sumatriptan nasal spray for children over 12 years of age for those with persistent symptoms. Antiemetics remain an option for those with nausea and/or vomiting as a prominent feature of their illness. Other treatments such as ketorolac are still being investigated in children.

Management of migraine in adolescents

Headaches in children and adolescents are still under-diagnosed. 75% of children are affected by primary headache by the age of 15 with 28% fitting the ICHD2 criteria of migraine. Migraine is considered a chronic disorder that can severely impact a child's daily activities, including schooling and socializing. Early recognition and aggressive therapy, with acute and prophylactic treatments, as well as intensive biobehavioral interventions, are essential to control the migraine attacks and reverse the progression into intractable disabling headache.

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

OBJECTIVE

To evaluate which treatment could be effective in the emergency department (ED) for children with migraine and status migrainosus, we carried out a qualitative systematic review of randomized controlled trials (RCTs) that evaluated treatment that could be used for those conditions.

METHODS

Databases (Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effects, Cochrane Controlled Trials Register, MedLine, and EMBASE) were searched for RCTs that evaluated treatment of migraine in children (<18 years of age). Guidelines published on the subject were checked for missed references. Characteristics of the identified studies as well as primary outcome (headache relief), other recognized primary outcomes, and adverse events were abstracted. Quality of the RCTs was evaluated using the Jadad score.

RESULTS

Of the 14 trials included in the review, only 1 was performed in an ED after other treatments have failed. In that situation, prochlorperazine was more effective than ketorolac in relieving pain at 1 hour. Other treatments were evaluated by neurologists on their outpatients who started the studied drugs early at the beginning of the migraine without previous treatment. In that situation, ibuprofen (n = 3) and acetaminophen (n = 1) were better than placebo for pain relief. The efficacy of intranasal sumatriptan (n = 4), oral rizatriptan (n = 3), and oral zolmitriptan (n = 2) for pain relief was unclear. Oral sumatriptan (n = 1) and oral dihydroergotamine (n = 1) were not effective.

CONCLUSIONS

There is a lack of studies addressing the question of treatment in the ED for children experiencing migraine. Although other treatments were found effective in children with migraine, none was evaluated in the ED except prochlorperazine and ketorolac.

Diagnosing and managing headache in children

Once the correct diagnosis of migraine in a child is established, a treatment plan can be developed. This often entails a combination of acute therapies, preventive therapies, and biobehavioral interventions. Goals of treatment should be clearly established for the patients and parents, and realistic time courses discussed. Overall outcome in terms of disability and quality of life also may need to be addressed and included within the evaluation and management scheme.

Acute treatment of paediatric migraine: a meta-analysis of efficacy

AIM

To undertake a meta-analysis of all randomised controlled trials (RCTs) on the acute pharmacologic treatment of children and adolescents with migraine headache.

METHODS

In total, 139 abstracts of clinical trials specific to the acute treatment of paediatric migraine were appraised. Inclusion criteria required clinical trials to be randomised, blinded, placebo-controlled studies with comparable endpoints. Non- English language publications were excluded. 11 clinical trials qualified for inclusion in the final meta-analysis. Two endpoints were analysed: the proportion of patients with (1) headache relief, and (2) complete pain relief, 2 h post-treatment.

RESULTS

The following medications were included in the analysis: acetaminophen (n = 1), ibuprofen (n = 2), sumatriptan (n = 5), zolmitriptan (n = 1), rizatriptan (n = 2) and dihydroergotamine (n = 1). Results are expressed as a relative benefit (RB) conferred over placebo and the number needed to treat (NNT). Only ibuprofen and sumatriptan provided a statistically significant relative efficacy in comparison with placebo. Two hours post-treatment, ibuprofen was associated with an RB 1.50 (95% CI 1.15-1.95) in the generation of headache relief (NNT 2.4) and RB 1.92 (95% CI 1.28-2.86) in the production of complete pain relief (NNT 4.9). Sumatriptan rendered an RB 1.26 (95% CI 1.13-1.41) in headache relief (NNT 7.4) and an RB 1.56 (95% CI 1.26-1.93) in the production of complete pain relief (NNT 6.9).

CONCLUSION

Despite the pharmacological options for the management of acute migraine, few RCTs in the paediatric population exist. Composite data demonstrate that only ibuprofen and sumatriptan are significantly more effective than placebo in the generation of headache relief in children and adolescents.