2C. ACUTE MIGRAINE - CHILDREN:1. ACETAMINOPHEN: CHILDREN: 15 mg/kg PO; repeat once after 2 h, then Q4-6H: maximum total dose, 100mg/kg/d.2. IBUPROFEN: CHILDREN: 10 mg/kg PO; repeat once after 2 h, then Q4-6H: maximum total dose, 40 mg/kg/d.3. PROCHLORPERAZINE: May give alone or as adjunct therapy.a. IM: CHILDREN LESS THAN 12 YEARS: 0.06 mg/lb IM.b. PR: CHILDREN OVER 2 YEARS: 20 to 29 pounds: 2.5 mg PR QD or BID (maximum, 7.5 mg/day); 30 to 39pounds: 2.5 mg PR BID or TID (maximum, 10 mg/day); 40 to 85 pounds: 2.5 mg PR TID or 5 mg PR BID(maximum, 15 mg/day).D. IV FLUIDS: 1 to 2 L NS in dehydrated adult patients with excessive vomiting.
0.2 CLINICAL PRESENTATION
A. DEFINITION: Recurrent headaches with initial intracranial vasoconstriction followed by extracranial vasodilation.B. TYPES: Migraine without aura, migraine with aura, migraine equivalents (basilar, ophthalmoplegic, hemiplegicmigraine).C. EPIDEMIOLOGY: Onset usually in childhood, adolescence, or early adulthood; more common in females; family historyoften present.D. PATHOPHYSIOLOGY: Complex disorder involving many levels of brain and neurovascular physiology; generation ofheadache probably is related to inflammatory result of trigeminal activation.E. PREDISPOSING FACTORS: Stress, premenstrual tension and fluid retention, drugs (eg, vasodilators, oral contraceptives,nitroglycerin), seasonal variation.F. CLINICAL FINDINGS: Typical migrainous attack characterized by unilateral, throbbing moderate to severe headache intemporal, orbital, or frontal distribution that lasts several hours to 2 days and is aggravated by routine physical activity.Migraine with aura preceded by transient neurologic symptoms. Migraine equivalents associated with focal neurologicdisturbances without headache or vomiting.1. VITAL SIGNS: Fever (rare); tachycardia, hyperventilation possible.2. SKIN: Pallor common.3. HEENT: Hemianopic field defects, scotomas, scintillations that enlarge and spread peripherally (aura) are earlysigns; blurred vision, photophobia, scalp tenderness may be present; unilateral eye pain with limitation of extraocularmovement (ophthalmoplegic migraine).4. GI: Nausea, vomiting are common; abdominal pain and distention may be more common in children.5. CNS: Headache (commonly unilateral, throbbing), vertigo, syncope, transient focal neurologic signs; ataxia,dysarthria (basilar artery migraine); motor deficits (hemiplegic migraine).6. PSYCHIATRIC: Mood alterations, emotional changes.7. MISCELLANEOUS: Weight gain (fluid retention), fatigue.
A. LABORATORY:1. Typically not helpful in the diagnosis and treatment of migraine headaches.B. RADIOLOGY:1. CT or MRI: Helpful in differentiating migraine symptoms from those of other entities, eg, aneurysm, mass lesion,or subdural hematoma. Consider in patients with nonacute headache and unexplained abnormal neurologic findingsand in patients with atypical headaches or headaches that do not fulfill strict definition of migraine or other primaryheadache. Not usually warranted in patients with migraine and normal neurologic examination.
0.4 DIFFERENTIAL DIAGNOSIS
A. Includes other types of primary headaches (tension-type and cluster) and secondary organic headache disorders,including SAH, meningitis, sinusitis, glaucoma, cerebrovascular disease.