If the child is headache free at emergency room discharge, the therapeutic focus shifts to ensuring the family has the tools they need to treat their next migraine attack effectively at home, thus preventing a repeat emergency room visit. One aspect of this is ensuring that the patient has a follow-up visit in place, ideally with a provider experienced in pediatric headache. Observational data suggests that pediatric patients who are followed in a headache center are unlikely to come to the ED for an acute attack, though this remains to be studied in a prospective fashion(13
At discharge the patient must be provided with at least one rescue treatment option that is appropriate for their level of migraine severity. By virtue of having presented to the emergency room, these children have usually demonstrated that they are capable of having at least moderately severe migraine attacks, and hence it may not be appropriate for them to have only non-specific analgesics for home rescue options. The AAN and Child Neurology Society practice parameter recommends the use of “migraine-specific agents in patients whose headaches respond poorly” to NSAIDs or acetaminophen(28
). Triptans are migraine-specific therapies that are appropriate for the treatment of moderate and severe migraine attacks. It is possible that clinicians are still uncomfortable prescribing triptans to children, as evidenced by the fact that pediatric migraineurs leaving pediatric emergency rooms received opioids 5.4% of the time but triptans only 1% of the time(8
). However, the medical-literature evidence base supporting the use of triptans in children has grown and their treatment should reflect this. For adolescents, almotriptan is FDA approved for acute migraine and should not be withheld in the absence of a medical contraindication. For younger children, or for those whom nausea makes an oral medication untenable, nasal spray sumatriptan and zolmitriptan have been proven efficacious and safe in randomized, placebo-controlled trials. Sumatriptan is available as a generic and some insurance carriers may require a trial of this medication before granting approval of newer triptans. Combining triptans with NSAIDs improves efficacy and reduces rebound headache after ED discharge in adults(89
). The efficacy and safety of the combination of sumatriptan and naproxen in adolescents has been established(54
). DHE is also a migraine-specific therapy that can be administered at home via nasal spray or injection.
Dopamine receptor antagonists represent another option for home use, particularly with those children who have significant nausea or vomiting. If the clinician has any concerns regarding possible cardiac effects at home, checking an ECG to rule-out long-QT syndrome would be non-invasive and reassuring. Prochlorperazine can be administered at home orally, by injection, or per rectum.
Recurrent emergency room visits for pediatric migraine are not uncommon. In one study, 12% of pediatric migraineurs returned to the ED within seven days(7
) and in another 11.2% returned within a month of their initial visit(9
); nearly half (42.9%) of this latter group ultimately returned for a third visit(9
). Clearly strategies for preventing emergency room bounce back are needed, though no such strategies have been specifically studied in children.
There are some data in adults to suggest that a single parenteral dose of corticosteroids at ED discharge, while not helpful in treating migraine acutely, may decrease the likelihood of headache recurrence at twenty-four hours. Some clinicians have adopted this practice in children, and it appears 2.4%-10% of children with migraine are prescribed corticosteroids on discharge from the emergency room(8
). It is important to remember however that many return ED visits for migraine take place after the initial twenty-four hours, and there are no data to suggest that corticosteroids prevent these visits. In fact, corticosteroids did not decrease the likelihood that a child would have a return ED visit within a month(9
). Additionally, if the practice were to become widespread, some children could accumulate a significant exposure to corticosteroids with their repeated emergency room visits. While rare, cases of avascular necrosis of the bone have been reported after relatively short courses of oral corticosteroids(90
If the child is not headache free at discharge, a course of standing naproxen may be useful. While naproxen is most often used as an acute migraine therapy, there are several positive trials demonstrating its efficacy as a preventive(94
), including a positive trend in a small adolescent study wherein patients were treated with 250 mg naproxen twice daily for six weeks (98
). One pediatric emergency room incorporates standing naproxen for seven days after discharge as part of their treatment protocol(7
). The potential for NSAIDs to cause medication overuse headache is unresolved(26
), and in moderate use they protect against conversion to chronic migraine in adults(25
). Suitable gastric protection, i.e. a proton-pump inhibitor or H2
blocker, can be added if necessary.
Admission to the hospital for acute migraine has many downsides, including significant sleep disruption and likely exacerbation of photophobia and phonophobia. Furthermore, admitting the patient provides no guarantee that the headache will break in the hospital, as evidenced by the fact that 25.6% of pediatric patients admitted acutely for “status migraine” were still not headache free after twenty doses of DHE, a treatment course which would have taken nearly seven inpatient days to administer(78
). Evidence from adults informs us that the benefit of an inpatient course of intravenous DHE is cumulative through the first month after discharge, with headache freedom obtained in the first few weeks after discharge rather than during the admission in a significant subset of patients(79
). Therefore the goal for any admission for migraine should be to provide an adequate dose of DHE, safely and with good nausea control, with the clearly set expectation that the headache will not necessarily abate during the admission.
Migraine is a common pediatric problem in the emergency room. Direct trial evidence for treatment of pediatric migraine in the emergency room is quite limited, therefore clinical decision making is largely guided by adult data and pediatric data collected in the outpatient setting. More pediatric migraine treatment trials in the emergency department setting are clearly needed.