Abstract
Status migrainosus is defined by the international classification of headache disorders (ICHD) criteria as a debilitating migraine lasting more then 72 hours. The epidemiology of status migrainosus is still unknown in adult and children, and frequently underdiagnosed.
Children and adolescents often end up in the emergency room with an intractable headache that failed outpatient therapy. Six to seven percent of these children do not respond to acute infusion therapy and require hospitalization.
It is imperative that more aggressive therapy is considered when patients are affected by a severe intractable headache to prevent further disability and returning the child to baseline activity...
When a headache lasts more than 72 hours, the diagnosis of status migrainosus is applied. Status migrainosus is considered a complication of migraine according to the new ICHD-III beta criteria (1.4.1), defined as a debilitating migraine attack with emphasis on the severity, disability and the need of aggressive therapy for quick relief...
This debilitating headache can occur in a child with intermittent migraine or as an exacerbation on top of a chronic headache. Akhtar and Rothner performed a retrospective review of status migrainosus over 8 years and were able to only clearly define 14 patients with status migrainosus: 8/14 had an occurrence in the setting of intermittent migraine and 3/14 had the exacerbation on top of a chronic migraine. Regardless, the exacerbation should be treated promptly. The prevalence of status migrainosus is likely much higher than was described by Akhtar and Rothner. Their study was probably limited by a lack of detailed information in the charts reviewed...
Raskin introduced his protocol of repeated doses of DHE intravenously in 1986. DHE has not been studied extensively in pediatric populations but a select few small studies showed tolerability and efficacy including Linder's study in 1994: his data included patients with ages ranging between 8 and 22 years who received IV DHE and oral metoclopramide; the dosage was adjusted to the age of the patient and clinical response.
Patients who fail ED/infusion therapy are hospitalized for a few days for aggressive therapy with DHE.
Patients are pre-medicated with prochlorperazine (0.13–0.15 mg/kg) 30 minutes prior to the DHE dosing, trying to prevent frequent nausea and vomiting that occurs with treatment. Prochlorperazine was preferred to the use of metoclopramide due to multiple studies showing higher efficacy than the metoclopramide as well as decreased rate of rebound after discharge from the emergency room when prochlorperazine is used compared to the metoclopramide. A dose of DHE of 0.5–1 mg (depending on age and weight) is given every 8 hours until headache freedom plus one extra dose when the headache stops. Prochlorperazine is stopped after three doses to prevent any extrapyramidal syndrome and is replaced by a different antiemetic such as ondansetron.
Diphenhydramine is often used preventively for extrapyramidal symptoms...
Sodium valproate should be considered when DHE fails or is contraindicated. One study recommends the use of sodium valproate as a bolus of 15 mg/kg followed by 5 mg/kg every 8 hours until the headache breaks or when the maximum dose of 10 doses is reached...
Intravenous magnesium sulfate has shown to be safe and effective for migraine in adults in intravenous infusion. One study showed the efficacy in patients 14–55 years of age that correlated well with the basal ionized magnesium blood level.
Magnesium sulfate does not have extensive research data published specific to pediatric populations and should only be considered as an alternative when DHE has failed or is contraindicated...
No placebo controlled studies are available yet for the pediatric population. It is still used frequently in an emergency setting as well as inpatient settings in children and adolescents. Akhtar and Rothner recommend the following in their paper: methylprednisolone 1 mg/kg/dose as a loading dose; dexamethasone 0.25–0.5 mg/kg/dose in a loading dose.
http://www.medscape.com/viewarticle/854831_print
See: Acute childhood migraine management
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