Tuesday, October 27, 2015

Acute childhood migraine management

Chen L, Alfonzo M. Acute Migraine Management in Children. Pediatr Emerg Care.
2015 Oct;31(10):722-7.


Migraines are common, incapacitating, and often stress inducing for pediatric patients and parents alike. According to the Agency for Healthcare Research and Quality, more than 1 million Americans seek emergency care every year due to migraines, with increasing frequency among adolescents. The disease can vary in severity and character, often mimicking life-threatening conditions, requiring prompt nuanced recognition by emergency personnel and implementation of an effective treatment strategy. Development of emergency department guidelines for the management of pediatric migraines should be based on up-to-date evidence supporting safe, appropriate therapies for children.

* Ibuprofen 10 mg/kg per dose (maximum, 800 mg) given orally every 6 hours as needed.
* Ketorolac 0.5 mg/kg intravenously (maximum, 30 mg) given every 6 hours as needed.
* Acetaminophen 15 mg/kg per dose (maximum, 1000 mg) given orally every 4 to 6 hours as needed (maximum daily dose, 75 mg/kg or 4 g).
* Almotriptan 6.25 to 12.5 mg tablet orally for children aged older than 12 years.

* Eletriptan 40 mg tablet orally for children aged older than 12 years.

* Rizatriptan 5 to 10 mg tablet or melt away orally for children aged older than 6 years.

* Sumatriptan 5 to 20 mg intranasally or 6 mg subcutaneously for children aged older than 12 years;
* Zolmitriptan 2.5 to 5 mg tablet or melt away orally, 5 mg nasal spray for children aged older than 12 years.
* Prochlorperazine 0.1 to 0.15 mg/kg given intramuscularly or intravenously (maximum daily dose, 7.5-20 mg based on weight) for children aged older than 2 years; associated with QTc prolongation.

* Chlorpromazine 0.25 to 0.55 mg/kg given orally, intramuscularly, or intravenously (maximum daily dose, 40-75 mg based on weight) for children aged older than 6 months; associated with QTc prolongation and hypotension; included for completeness; recent data suggests poor effectiveness among children.17

* Metoclopramide 0.1 to 0.2 mg/kg per dose (maximum dose, 10 mg).
* Low-dose DHE 0.1 to 0.2 mg given intravenously every 6 hours (maximum, 16 doses) or high-dose DHE 0.5 to 1 mg given intravenously every 8 hours (maximum, 20 doses), along with intravenous rehydration and antiemetic pretreatment; may require multiple doses for effect.
* Standardized treatments often consist of intravenous therapy with normal saline fluid bolus, ketorolac, DRA, and diphenhydramine (1 mg/kg per dose to a maximum of 50 mg).

1 comment:

  1. Patniyot IR, Gelfand AA. Acute Treatment Therapies for Pediatric Migraine: A Qualitative Systematic Review. Headache. 2016 Jan;56(1):49-70.



    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.


    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.


    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.


    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.

    Courtesy of: http://www.mdlinx.com/neurology/medical-news-article/2016/01/25/pediatric-headache-emergency-room-headache-treatment/6504396/?category=sub-specialty&page_id=1&subspec_id=317