Migraine Cocktail

Migraine Cocktail

 

Naturally, the differential for headache in pediatric patients is vast and includes conditions ranging from strep throat to Pseudotumor and pneumonia to AVM. Occasionally, we have to perform invasive tests like Lumbar Punctures to help evaluate the headache. Fortunately, most often the cause of the headache is not a severe pathologic one. While it may be a more benign condition in our minds, though, let us not be cavalier with the Pediatric Migraine patient.

 

Pediatric Migraine

  • Headaches are common in the ED
    • 2-3% of ED for all ages.
    • Account for ~1% of Ped ED visits
    • Most headaches are due to benign causes.
  • Prevalence of Pediatric Migraine
    • Difficult to know true prevalence.
    • Increases with age:
      • 3-7 yrs: 1-3%
      • 7-11yrs: 4-11%
      • by 15yrs: 8-23%
    • Typically have had 2-3 days of headache prior to ED presentation.
    • Often (>60%) have already tried abortive therapies. [Richer, 2010]
    • Most are able to be treated effectively in the ED and discharged to home. [Bachur, 2015]

 

Migraine Therapies for Kids

  • Ibuprofen
    • Effective and safe [Evers, 2006; Lewis, 2002]
    • Considered by many to be first line therapy, but often used by patient prior to arrival in ED.
  • Triptans
    • NOT FDA approved for use in children, and are used “off label.”
    • Evidence that NSAID is equally efficacious.
    • Sumatriptan nasal spray has been shown to be safe and efficacious for adolescents. [Lewis, 2004; Winner, 2000]
    • Combination of Sumatriptan with NSAID has shown to be effective in adolescents also. [Derosier, 2012]
    • No ED-Based studies of use of triptans for children available yet.
  • Prochlorperazine
    • Shown to be more effective than IV NSAID (my least favorite NSAID). [Brousseau, 2004]
    • Recent publication showed that prochlorperazine use was associated with lower rate of return ED visits compared to metoclopramide (certainly not causal relationship). [Bachur, 2015]
    • Often administered with diphenhydramine to prevent akathisia, although also found to be associated with higher return ED visit rates. [Bachur, 2015]

 

Migraine Approach (in my humble opinion)

  • Do a thorough neuro exam!
    • Channel your inner neurologist.
    • Documenting a truly normal neuro exam goes a long way toward defining this headache as a benign one.
  • Do a Fundoscopic exam!
    • Again, let us make sure we are not missing pseudotumor… or a real tumor.
    • A PanOptic Ophthalmoscope is much easier to use on kids!
  • Headaches suck… don’t be dismissive.
    • After you have decided that this is a benign headache, realize that the kid doesn’t think it is benign.
  • Try a Triptan
    • If the patient is an adolescent, this is a reasonable option.
  • One Migraine Cocktail Coming Up.
    • There appears to be some evidence to favor Prochlorperazine over metoclopramide.
    • Keep diphenhydramine handy… remember that you should first do no harm.

 

References

Bachur RG1, Monuteaux MC2, Neuman MI2. A comparison of acute treatment regimens for migraine in the emergency department. Pediatrics. 2015 Feb;135(2):232-8. PMID: 25624377. [PubMed] [Read by QxMD]

Derosier FJ1, Lewis D, Hershey AD, Winner PK, Pearlman E, Rothner AD, Linder SL, Goodman DK, Jimenez TB, Granberry WK, Runken MC. Randomized trial of sumatriptan and naproxen sodium combination in adolescent migraine. Pediatrics. 2012 Jun;129(6):e1411-20. PMID: 22585767. [PubMed] [Read by QxMD]

Trottier ED1, Bailey B, Lucas N, Lortie A. Prochlorperazine in children with migraine: a look at its effectiveness and rate of akathisia. Am J Emerg Med. 2012 Mar;30(3):456-63. PMID: 21296523. [PubMed] [Read by QxMD]

Richer LP1, Laycock K, Millar K, Fitzpatrick E, Khangura S, Bhatt M, Guimont C, Neto G, Noseworthy S, Siemens R, Gouin S, Rowe BH; Pediatric Emergency Research Canada Emergency Department Migraine Group. Treatment of children with migraine in emergency departments: national practice variation study. Pediatrics. 2010 Jul;126(1):e150-5. PMID: 20530076. [PubMed] [Read by QxMD]

Evers S1, Rahmann A, Kraemer C, Kurlemann G, Debus O, Husstedt IW, Frese A. Treatment of childhood migraine attacks with oral zolmitriptan and ibuprofen. Neurology. 2006 Aug 8;67(3):497-9. PMID: 16775229. [PubMed] [Read by QxMD]

Brousseau DC1, Duffy SJ, Anderson AC, Linakis JG. Treatment of pediatric migraine headaches: a randomized, double-blind trial of prochlorperazine versus ketorolac. Ann Emerg Med. 2004 Feb;43(2):256-62. PMID: 14747817. [PubMed] [Read by QxMD]

Lewis D1, Ashwal S, Hershey A, Hirtz D, Yonker M, Silberstein S; American Academy of Neurology Quality Standards Subcommittee; Practice Committee of the Child Neurology Society. Practice parameter: pharmacological treatment of migraine headache in children and adolescents: report of the American Academy of Neurology Quality Standards Subcommittee and the Practice Committee of the Child Neurology Society. Neurology. 2004 Dec 28;63(12):2215-24. PMID: 15623677. [PubMed] [Read by QxMD]

Lewis DW1, Kellstein D, Dahl G, Burke B, Frank LM, Toor S, Northam RS, White LW, Lawson L. Children’s ibuprofen suspension for the acute treatment of pediatric migraine. Headache. 2002 Sep;42(8):780-6. PMID: 12390641. [PubMed] [Read by QxMD]

Winner P1, Rothner AD, Saper J, Nett R, Asgharnejad M, Laurenza A, Austin R, Peykamian M. A randomized, double-blind, placebo-controlled study of sumatriptan nasal spray in the treatment of acute migraine in adolescents. Pediatrics. 2000 Nov;106(5):989-97. PMID: 11061765. [PubMed] [Read by QxMD]

Sean Fox

I enjoy taking care of patients and I finding it endlessly rewarding to help train others to do the same. I trained at the Combined Emergency Medicine and Pediatrics residency program at University of Maryland, where I had the tremendous fortune of learning from world renown educators and clinicians. Now I have the unbelievable honor of working with an unbelievably gifted group of practitioners at Carolinas Medical Center. I strive every day to inspire my residents as much as they inspire me.

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2 Responses

  1. February 12, 2015

    […] If you’re a regular reader of the blog you know that I’ve posted on migraines before. For instance, you can check out the “Why We Do What We Do” on antiemetics (prochlorperazine and metoclopramide). Other excellent Pediatric Emergency Medicine educators have posted on the topic recently as well – see Sean Fox’s recent post on PedEMMorsels. […]

  2. January 20, 2017

    […] conditions to consider when evaluating headache (ex, AVM, RMSF, Meningitis, Post-LP, Moyamoya, Migraine, Pseudotumor, and Pheochromocytoma). Many of these are rare and require our dedicated vigilance to […]

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