According to recent estimates, about 250,000 children and adolescents present to the ED each year with a complaint of headaches. At the time when these patients present to the ED, most sufferers of these headaches have experienced pain for 2 to 3 days and many have already used more than one abortive therapy. Despite this relatively frequent occurrence, few studies on the treatment of primary headache in the ED setting have been conducted in children and adolescents.
Historically, studies involving the treatment of pediatric headache in the ED have been limited to retrospective reviews. As a result, many current practices for emergency room treatment of pediatric headache are based on adult trials or studies performed in non-ED settings. “Throughout the United States, the management of pediatric acute migraine varies across EDs,” says Irene R. Patniyot, MD. “In addition, evidence-based treatment is not always administered.” She adds that the last set of guidelines for managing pediatric migraine was published more than a decade ago.
A Systematic Review
For a study published in Headache, Dr. Patniyot and colleagues conducted a systematic review to explore the safety and efficacy of available treatments for pediatric patients with migraine or benign primary headaches in the ED. The goal of the analysis was to inform future practices and research and identify acute therapies that can be safely and effectively administered in the ED. The review included 31 studies in the final analysis, which consisted of patients younger than 18 years of age. Of these studies, 17 were randomized controlled trials, nine were retrospective reviews, and five were prospective chart review studies.
“Our study showed that pediatric migraine is difficult to treat in the ED because there are no diagnostic tests to determine severity and course of action, and many patients try different therapies before they present to the emergency room,” Dr. Patniyot says. Results indicated that several treatments were effective for acute migraine or benign primary headache in the analgesic category. These included ibuprofen and, to a lesser degree, acetaminophen. Ketorolac was not compared with other NSAIDs but was found to be less effective than prochlorperazine.
Overall, prochlorperazine was considered the most effective agent in the phenothiazine class, but the lack of more robust data indicates that formal comparative efficacy studies are needed. “The phenothiazine class of drugs, specifically prochlorperazine, should not be overlooked when managing pediatric migraine in the ED,” says Dr. Patniyot. “Several triptan medications also appear to be effective for acute pediatric migraine treatment. Both phenothiazines and triptans should be considered safer and more effective therapies than opioids for pediatric migraines.”
Some treatments were considered probably effective for the management of pediatric migraine in the ED, including intravenous fluids, chlorpromazine, valproate sodium, injectable sumatriptan, and IV dihydroergotamine (DHE). Oral zolmitriptan use yielded inconsistent results, while some treatments were considered ineffective, including isolated oral sumatriptan and oral DHE. There was insufficient evidence to comment on propofol, magnesium, and bupivicaine efficacy.
“Based on current evidence, it appears that ibuprofen, prochlorperazine, and certain triptan medications are the most effective and safe agents for acutely managing migraine and other benign headache disorders in the children and adolescents in the ED,” says Dr. Patniyot. “Most treatments were well tolerated, but additional studies are needed in this patient population.” The study notes that clinicians should consider other important variables in future research, such as dosing, co-administered medications, treatment duration, and length of treatment effect.
Irene R. Patniyot, MD, has indicated to Physician’s Weekly that she has no financial disclosures to report.
Readings & Resources (click to view)
Patniyot IR, Gelfand AA. Acute treatment therapies for pediatric migraine: a qualitative systematic review. Headache. 2016;56:49-70. Available at: http://onlinelibrary.wiley.com/doi/10.1111/head.12746/pdf.
Richer LP, Laycock K, Millar K, et al. Treatment of children with migraine in emergency departments: National practice variation study. Pediatrics. 2010;126:e150-e155.
Eapen A, Sivaswamy L, Agarwal R, Thomas R. Management of pediatric migraine in a tertiary care versus community based emergency department: An observational pilot study. Pediatr Neurol. 2014;50:164-170.
Legault G, Eisman H, Shevell MI. Treatment of pediatric status migrainosus: can we prevent the “Bounce Back”? J Child Neurol. 2011;26:949–955.