Researchers conducted a retrospective chart review of 58 encounters of 38 pediatric patients with refractory headache.
Treatment with IV ketamine led to 50% pain reduction at discharge.
Treatment with IV ketamine for pediatric refractory headache resulted in a 50% reduction in pain at discharge, with nearly two-thirds of patients not requiring rescue care within 1 month, according to a poster presentation.
“Patients with severe and refractory headaches often have few options for treatment despite ongoing pain and significant disability,” Scott Rosenthal, MD, a child neurology resident in the department of pediatrics at University of Colorado Anschutz Medical Campus, and colleagues wrote. “Ketamine has emerged as a potential therapeutic option and had demonstrated benefit in other chronic pain syndromes.”
Researchers conducted a retrospective chart review of 58 encounters of 38 patients aged 5 to 21 years (median age, 15.8 years; 76% girls) who were admitted to Children’s Hospital Colorado between 2019 and 2022 for treatment of refractory headache with continuous IV ketamine.
The primary outcome was percent pain reduction at discharge compared with baseline, headache recurrence within 72 hours, headache recurrence within 30 days of discharge, side effects of medication and serious adverse events.
According to results, treatment resulted in a 50% median pain reduction at discharge, with 64% of patients reporting no headache recurrence within 1 month of hospital discharge.
Among patients with recurrence, median time was 7 days, with 9% experiencing recurrence within 72 hours.
While no serious adverse events were reported, 7% of encounters stopped treatment because of side effects.
“Intravenous ketamine is an effective, safe and well-tolerated treatment option for refractory pediatric headaches and status migrainosus,” Rosenthal and colleagues wrote.
Treatment with IV ketamine led to 50% pain reduction at discharge.
Treatment with IV ketamine for pediatric refractory headache resulted in a 50% reduction in pain at discharge, with nearly two-thirds of patients not requiring rescue care within 1 month, according to a poster presentation.
“Patients with severe and refractory headaches often have few options for treatment despite ongoing pain and significant disability,” Scott Rosenthal, MD, a child neurology resident in the department of pediatrics at University of Colorado Anschutz Medical Campus, and colleagues wrote. “Ketamine has emerged as a potential therapeutic option and had demonstrated benefit in other chronic pain syndromes.”
Researchers conducted a retrospective chart review of 58 encounters of 38 patients aged 5 to 21 years (median age, 15.8 years; 76% girls) who were admitted to Children’s Hospital Colorado between 2019 and 2022 for treatment of refractory headache with continuous IV ketamine.
The primary outcome was percent pain reduction at discharge compared with baseline, headache recurrence within 72 hours, headache recurrence within 30 days of discharge, side effects of medication and serious adverse events.
According to results, treatment resulted in a 50% median pain reduction at discharge, with 64% of patients reporting no headache recurrence within 1 month of hospital discharge.
Among patients with recurrence, median time was 7 days, with 9% experiencing recurrence within 72 hours.
While no serious adverse events were reported, 7% of encounters stopped treatment because of side effects.
“Intravenous ketamine is an effective, safe and well-tolerated treatment option for refractory pediatric headaches and status migrainosus,” Rosenthal and colleagues wrote.
https://www.healio.com/news/neurology/20230629/iv-ketamine-reduced-pain-by-50-in-pediatric-patients-with-refractory-headache
Conferences|American Headache Society Annual Scientific Meeting
The use of intravenous ketamine in pediatric patients with refractory headaches resulted in a median pain reduction of 50% at discharge and nearly two-third of patients did not need further rescue therapies 1 month posttreatment.
Findings from a recent study of pediatric patients with refractory migraine demonstrated a significant reduction in pain at discharge using intravenous ketamine as a treatment with no serious adverse events. These results suggest that intravenous ketamine is an effective, safe, and well-tolerated option for treating refractory pediatric headaches and status migrainosus.
All told, the median percent pain reduction at discharge was 50% (IQR -67% to +25%) among 58 encounters with pediatric patients with refractory migraine. Of note, 64% of patients did not have headache recurrence or exacerbation in 1 month after discharge. Notably, the median time to recurrence was 7 days (IQR, 3-12.5) for those that recurred and 9% had recurrence in 72 hours postdischarge.
"Patients with severe and refractory headaches often have few options for treatment despite ongoing pain and significant disability. While intravenous dihydroergotamine (IV DHE), an ergot derivative with 5HT agonism, is often effective for the majority of pediatric patients presenting with status migrainosus and refractory headaches, a significant proportion of patients will fail to respond or cannot receive IV DHE due to intolerability/contraindications," lead author Scott Rosenthal, MD, a child neurology resident at Children's Hospital Colorado, University of Colorado School of Medicine and colleagues wrote.1
Presented at the 2023 American Headache Society (AHS) Annual Meeting, June 15-18, in Austin, Texas, researchers conducted a retrospective chart review of patients between the ages of 5 and 21 years old. To be eligible, the patients had to be admitted to a tertiary pediatric referral center for the treatment of refractory headache. Patients were excluded if they received both ketamine and IV dihydroergotamine (DHE) in the same period, had a secondary etiology for headache, or had a pain score that was less than 3 on a verbal analogue scale at presentation.
Investigators used the percentage of pain reduction at discharge ([Discharge Pain Score - Initial Pain Score]/Initial Pain Score*100) as the primary outcome, while also observing serious adverse events, medication adverse effects, headache recurrence in 72 hours, and headache recurrence in 30 days postdischarge. Investigators defined headache recurrence if patients made a phone call or representation of care for headache requiring rescue therapy. Demographic variables from the patients were also collected.
In the analysis, 58 encounters comprised of 38 unique pediatric patients with a median age of 15.8 years (IQR 13.42-17.41), 76% of which identified as women, were included. Seventy-eight percent of patients were diagnosed as chronic migraine without aura and he median duration of headache or headache pain exacerbation at presentation was 10 days (IQR, 3-26.5). Also, the median maximum dose of intravenous ketamine was 0.28 mg/kg/hour (IQR, 0.2-0.4), with the median duration of infusion being 3 days (IQR, 2-3).
Although there were no serious adverse events reported in the analysis, the most common adverse effects were dizziness (19%), nausea (12%), hallucinations (12%), blurry vision (12%), cognitive fog (9%), dysphoria (5%) and vomiting (4%). Notably, only 7% of encounters had discontinued therapy early because of the adverse events the patients experienced.
"Ketamine, a NMDA receptor antagonist, has emerged as potential therapeutic option for this population and has demonstrated benefit in other chronic pain syndromes and refractory mood disorders. Unfortunately, there is a paucity of literature available about the efficacy and tolerability of IV ketamine in the treatment of refractory pediatric headaches and status migrainosus." Rosenthal et al noted.
https://www.neurologylive.com/view/intravenous-ketamine-significantly-reduces-pain-refractory-pediatric-headache
Rosenthal S, Ackley E, Koehler A, Yonker M. The Safety and Efficacy of Intravenous Ketamine in the Treatment of Refractory Pediatric Headache. Presented at: AHS Annual Meeting, 2023; June 15-18.
P-193
The Safety and Efficacy of Intravenous Ketamine in the Treatment of Refractory Pediatric Headache
Rosenthal S1, Ackley E, Koehler A, Yonker M
Children's Hospital Colorado, 13123 E. 16th Ave, United States
Intravenous ketamine represents a safe, tolerable, and efficacious treatment option for pediatric patients with refractory headaches.
Background: Patients with severe and refractory headaches often have few options for treatment despite ongoing pain and significant disability. While intravenous dihydroergotamine (IV DHE), an ergot derivative with 5HT agonism, is often effective for the majority of pediatric patients presenting with status migrainosus and refractory headaches, a significant proportion of patients will fail to respond or cannot receive IV DHE due to intolerability/contraindications. Ketamine, a NMDA receptor antagonist, has emerged as potential therapeutic option for this population and has demonstrated benefit in other chronic pain syndromes and refractory mood disorders. Unfortunately, there is a paucity of literature available about the efficacy and tolerability of IV ketamine in the treatment of refractory pediatric headaches and status migrainosus.
Methods: We conducted a retrospective chart review of patients 5-21 years old, admitted to a tertiary pediatric referral center between 2019-2022 for the treatment of refractory headache with continuous intravenous ketamine. Patients were excluded if they received both ketamine and IV DHE in the same encounter, had a secondary etiology for headache, or had a pain score < 3 (on verbal analogue scale, 0-10) at presentation. Primary outcome measures were percent pain reduction at discharge ([Discharge Pain Score - Initial Pain Score]/Initial Pain Score*100), serious adverse events, medication side effects, headache recurrence within 72 hours, and headache recurrence within 30 days post-discharge. Recurrence was defined as phone call or re-presentation to care for headache requiring rescue therapy. Demographic variables were also collected.
Results: 58 encounters comprised of 38 unique patients were included for analysis. The median age was 15.8 years (IQR 13.42-17.41) and 44/58 (76%) of patients identified as female. The most common diagnosis was chronic migraine without aura (45/58, 78%) and the median duration of headache or headache pain exacerbation at presentation was 10 days (IQR 3-26.5). The median maximum dose of ketamine was 0.28 mg/kg/hour (IQR 0.2-0.4) and the median duration of infusion was 3 days (IQR 2-3). The median percent pain reduction at discharge was 50% (IQR -67% to +25%). 37/58 (64%) of patients did not have headache recurrence or exacerbation with 1 month of discharge. Of those that recurred, the median time to recurrence was 7 days (IQR 3-12.5). 5/58 (9%) had recurrence with 72 hours of discharge. There were no serious adverse events. The most common side effects were dizziness (19%), nausea (12%), hallucinations (12%), blurry vision (12%), cognitive fog (9%), dysphoria (5%) and vomiting (4%). 4/58 (7%) encounters terminated therapy early due to side effects.
Conclusion: Intravenous ketamine is an effective, safe and well tolerated treatment option for refractory pediatric headaches and status migrainosus. There was a median pain reduction of 50% at discharge and nearly two-thirds of patients did not re-present for further rescue therapies within 1 month. There were no serious adverse events and side effects were very well tolerated.
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