You are working your evening shift at the pediatrics emergency department, and you walk into a darkened patient room with a distressed mother and her otherwise healthy 10-year old son who is curled in a ball, holding his head and crying. Her mother tells you that the around-the-clock ibuprofen has barely touched his 2-day headache.

After determining that your patient has no neurologic deficits and that this is most likely a primary headache, what can you do to break his symptoms?

The numbers

Headaches account for 1% of all pediatric emergency department visits. Of those presenting with headache, 40% of children are diagnosed with a primary headache, and 75% of these are migraines. Most research and medications have focused on children < 7 years ago as the average age of onset of migraines is 7 years old among boys and 11 years old among girls.1 The diagnosis of pediatric migraine can be challenging, especially in younger children (<7 yo) who may not be able to describe their symptoms.

Should you stick the kid?

Children may have been vomiting and have decreased oral intake. If you are feeling bad about placing an IV in your patient, just know that about half of patients with migraines will need IV therapy.2

Should you reach for that opioid?

According to the American Academy of Neurology, they recommend that opiate medications be avoided for the treatment of migraines in children. A study by DeVries found that among adolescents who received opioids, 28% had an emergency department revisit for their headache compared to only 14% who did not receive any opioids (P < 0.01).3 Dr. Amy Gelfand, a UCSF pediatric neurologist who specializes in pediatric headaches, says that by giving opioids, there is an associated decreased responsiveness to triptans in the future (See her Expert Peer Review comments below).

What should you try then?

By the time your patient present to the ED for migraines, they have been symptomatic for probably 24-72 hours already, and have taken some type of abortive medication, most often acetaminophen or ibuprofen.2,4 The addition of caffeine to ibuprofen may increase ibuprofen’s analgesic properties.4

Which dopamine-receptor antagonists to use?

Your choices of the phenothiazines for ages ≥7 years old include:

Prochlorperazine (1st choice)

Chlorpromazine

Metoclopramide

Pros: Alleviates both pain and nausea/vomiting

Cons: Drowsiness, hypotension, and extrapyramidal reactions (EPS).

In a recent study in Pediatrics 2015, Bachur et al. performed a large retrospective study, using data collected on children aged 7-18 years from 35 pediatric EDs.5 They examined any revisits within 3 days of initial encounter as their primary outcome. Common medications included:

Non-opioid analgesics (66%) Dopamine receptor antagonists (50%) Ddiphenhydramine (33%)

Of those discharged at the initial encounter, 5.5% of children had a return visit within 3 days.

They found that children treated with prochlorperazine had a 31% decreased odds of returning to the emergency department, compared to those treated with metoclopramide. Kanis et al. found that proclorperazine was more effective than chlopromazine, with less admission, need for rescue medications, shorter disposition times, and hypotensive events.6

Prophylactic diphenhydramine may be administered to patients receiving prochlorperazine to pre-treat akathisia and dystonic reactions. Diphenhydramine may cause additional sedation and drowsiness when co-administered with prochlorperazine. EPS may occur after ED discharge even in patients receiving prophylactic diphenhydramine, so parents should be cautioned about restlessness (akathesia) and dystonia.8

Brousseau et al. showed better efficacy with a 50% reduction of pain at 1 hour in children who received prochlorperazine IV (84.8%) versus ketorolac IV (55.2%) though 30% of both groups had recurrences of some headache 48 hours after treatment.7 Per Dr. Gelfand, prochlorperazine should be considered first-line over ketorolac.

Other regimens

Triptans may be administered via oral and subcutaneous routes, or via intranasal spray. In the ED, triptans may be useful in kids with migraines who do not take triptans as abortive therapy. In general, patients should not receive more than two doses of triptans in a 24-hour period. They work effectively at the earlier stages of the migraine when the symptoms are more mild compared to when there are more moderate or severe. Zolmitriptan nasal spray has recently been approved for children 12 years old and older, while sumitriptan nasal spray is available for children 5 years and older. When compared to placebo, triptans have a 2-hour efficacy for 42-86% of patients. Combination medications of triptans and naproxen have also been shown to have good efficacy.1,4 You can prescribe patients home with triptans, as long as there are no contraindications such as cardiac issues. Keep in mind the cost impact of these medications. Many triptans are still non-generic and patients without insurance may not have access to them. There are four triptans that are FDA-approved for acute migraine treatment in the <18 age group (See below for the dosing table).

IV dihydroergotamine (DHE) is primarily used in the inpatient setting, but could be initiated in the ED for refractory cases, given that it typically takes several doses over several hours to administer. DHE can worsen nausea and lead to emesis, therefore should be used in conjunction with an antiemetic or prochlorperazine (which also has anti-emetic properties). Avoid DHE and triptans together, especially for those patients with cardiovascular disease.1,4

If the history is consistent with migraine, the algorithm by Sheridan et al may be useful in your pocket for patients ≥7 years old:1

Bottom Line

Give hydration either by oral or by parenteral route. Dim the lights and turn down any loud sounds or alarms. Break the habit… Avoid opioids! Give prochlorperazine instead of metoclopramide or chlopromazine. Try a triptan. Refer to a neurologist. If your patient has migraines that are bad enough to have them land in the ED, they should be evaluated by a specialist, ideally one that has experience with managing pediatric migraines.

Dosages

Medications Dosage Simple analgesics Acetaminophen 15 mg/kg PO or PR (max 1 g/dose or 4 g/day) Ibuprofen 10 mg/kg PO (max dose 800 mg/dose or 2400 mg/day) Ketorolac 0.5 mg/kg IV (max dose 15 mg/dose) Dopamine antagonists Prochlorperazine 0.15 mg/kg IV (max dose 10 mg/dose) Metoclopramide 0.1 mg/kg IV ( max dose 10 mg/dose) 5HT receptor agonists Sumatriptan 5-20 mg IN 50-100 mg PO 3-6 subQ Almotriptan 6.25 or 12.5 mg PO for ages 12-17 years Rizatriptan MLT 5 mg (<40 kg) or 10 mg (≥40 kg) for >6 years old Zolmitriptan 2.5-5 mg IN for ages 12-17 years Treximet: Sumatriptan/Naproxen combination For ages 12-17 years: 10 mg/60 mg PO 85 mg/500 mg PO (max dose) Dihydroergotamine 0.5-1 mg SubQ, IM or IV Other anti-emetics Diphenhydramine 1 mg/kg (max dose 50 mg/dose) Promethazine 0.25-1 mg/kg IV (max dose 25 mg/dose) Table adapted from Sheridan, Bulloch and Dr. Gelfand’s comments below

1. Headache. 2014;54(2):235-245. PubMed] Sheridan D, Spiro D, Meckler G. Pediatric migraine: abortive management in the emergency department.. 2014;54(2):235-245. 2. Pediatr Emerg Care. 2000;16(3):196-201; quiz 203. PubMed] Bulloch B, Tenenbein M. Emergency department management of pediatric migraine.. 2000;16(3):196-201; quiz 203. 3. J Adolesc Health. 2014;55(1):128-133. PubMed] DeVries A, Koch T, Wall E, Getchius T, Chi W, Rosenberg A. Opioid use among adolescent patients treated for headache.. 2014;55(1):128-133. 4. Pediatr Neurol. 2012;47(4):233-241. PubMed] Gelfand A, Goadsby P. Treatment of pediatric migraine in the emergency room.. 2012;47(4):233-241. 5. Pediatrics. 2015;135(2):232-238. PubMed] Bachur R, Monuteaux M, Neuman M. A comparison of acute treatment regimens for migraine in the emergency department.. 2015;135(2):232-238. 6. Headache. 2014;54(2):335-342. PubMed] Kanis J, Timm N. Chlorpromazine for the treatment of migraine in a pediatric emergency department.. 2014;54(2):335-342. 7. Ann Emerg Med. 2004;43(2):256-262. PubMed] Brousseau D, Duffy S, Anderson A, Linakis J. Treatment of pediatric migraine headaches: a randomized, double-blind trial of prochlorperazine versus ketorolac.. 2004;43(2):256-262. 8. Coralic, PharmD Z. I am giving prochlorperazine. Should I give diphenhydramine too? ALiEM. https://www.aliem.com/2014/give-prochlorperazine-diphenhydramine/ . Published September 3, 2014. Accessed October 29, 2016.