Treatment of Pediatric Status Migrainosus

Abstract

The impact of treatment given upon discharge on the "bounce back" rate was ascertained in children presenting at the emergency department for treatment of status migrainosus. All children ages 8 to 17 years old presenting to an emergency department in 2008 who were treated for status migrainosus and discharged home were included. Of the total of 187 patients, 21 patients (11.2%) bounced back. Treatment given was not associated with the bounce back rate. The only factors reaching significance were the presence of a migraine equivalent in 28.6% of patients who bounced back as compared with only 6.7% in patients without recurrence (P = .006); brain imaging study in the emergency department (52.4% vs. 16.9%, P = .001); and an arranged physician follow-up (66.6% vs. 36.3%, P = .01). The results appear to suggest that no current treatment given to children presenting to the emergency department with status migrainosus seems to alter the immediate recurrence rate.

A Comparison of Acute Treatment Regimens for Migraine in the Emergency Department

“…The most common agents are prochlorperazine, chlorpromazine, promethazine, and metoclopramide. Although metoclopramide was the most common agent in previous reports of pediatric 5,8 and adult 19 migraine treatment in the ED setting, we observed that prochlorperazine and metoclopramide are used with equal frequency. Previous reports from adults have suggested that prochlorperazine might be more efficacious than metoclopramide, 20 and prochlorperazine's safety and effectiveness has been previously reported.…”

“…5,8 Triptans, a serotonin receptor agonist, have been increasingly used for treatment of acute migraine. Although they have the greatest value early in the course of illness, 24 most children with migraine present to the ED after experiencing prolonged symptoms at home.…”

“…Although they have the greatest value early in the course of illness, 24 most children with migraine present to the ED after experiencing prolonged symptoms at home. 5,8 Despite this, studies in adults have shown triptans to be effective as abortive therapy in the ED setting, 25 but there have not been any ED-based pediatric studies. The evidence for pediatric use of triptans in the outpatient setting is strong, [26][27][28][29] yet only 3% of children received a triptan in the current study.…”

“…In 1 study by Legault et al, 184 children with migraine headache were studied, and 11% returned to the ED within 1 month; of those that returned, 71% returned within 4 days of the initial visit. 8 No specific treatment at the initial encounter was associated with the return visit, although small sample size limited the ability to detect differences between treatments. In another study on the use of prochlorperazine, 100% had improvement in their migraine during the ED visit, but 68% had a partial relapse of their headache within 1 week of discharge 6 ; the authors did not report the rate of revisit to an ED.…”

“…By the time children present to an ED for migraine care, the headache has typically been present for 2 to 3 days, 6,8 and most patients have already tried some abortive therapy. 5,6 Treatment in a pediatric ED rather than a general ED has been associated with increased use of dopamine antagonists, less use of opioids, and increased rates of headache resolution.…”