EMERGENCY DEPARTMENT MANAGEMENT OF MIGRAINE IN CHILDREN: A PRACTICE VARIATION STUDY

Objectives: Evidence based guidelines for the treatment of children with migraine is limited given the paucity of randomized controlled trials. Our objectives were to: (1) characterize the treatment of children with migraine to identify areas of clinical uncertainty in preparation for future clinical trials; (2) determine the frequency of narcotic use.

Methods: Children aged 5 to 17 years presenting to the four regional hospitals in Edmonton, Alberta, Canada during the 2003/2004 fiscal year with a diagnostic code of headache or migraine were selected. A standardized retrospective chart abstraction was performed and migraine or probable migraine cases were classified based on the International Classification of Headache Disorders II.

Results: Three hundred and four headache cases were identified of which 58.2% (n=177/304) met sufficient criteria for migraine or probable migraine. Narcotic medications were prescribed in 13.6% of migraine patients while 29.4% received no treatment. Oral simple analgesics (27.7%) and intravenous therapy with a dopamine antagonist, non-steroidal anti-inflammatory (NSAID), or dihydroergotamine (28.2%) were prescribed at similar rates. No predictors were identified. Common therapeutic strategies included: (1) dopamine antagonist (i.e. metoclopramide or prochlorperazine) (35.6%); (2) combination of a dopamine antagonist and NSAID (10.2%; n=18); and (3) oral simple analgesic or NSAID (28.8%; n=51). Dihydroergotamine (6.8%), narcotics alone (6.2%) and steroids (1.7%) were used infrequently in migraine patients. Efficacy could not be determined although 98.4% of patients were discharged home. No significant side-effects were documented.

Conclusion: Clinical areas of uncertainty in the treatment of pediatric migraine include: (1) the use of oral therapy vs. intravenous therapy; (2) combination therapy (e.g. dopamine antagonist and NSAID) vs. dopamine antagonists alone; (3) the outcome of children when no therapy is prescribed; and (4) the efficacy of less common therapies including dihydroergotamine, steroids, and possibly narcotics. Future clinical trials are required to help physicians and emergency departments establish pediatric specific evidence-based guidelines in the treatment of migraine.