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Cefalea 4
Cefalea 4
https://doi.org/10.1007/s11910-020-01035-5
Abstract
Purpose of Review Pediatric migraine is common, and appropriate abortive treatment is important to limit impact on school
performance and mental health. This review will describe the latest evidence for abortive treatment in the emergency department
and inpatient settings.
Recent Findings It is recognized that a protocol for emergency department treatment can increase efficacy and prevent admis-
sions. These protocols commonly include a non-opioid analgesic and dopamine receptor antagonist. A novel approach to
treatment with valproic acid is use of a continuous infusion. Administration of ketamine or propofol and peripheral nerve blocks
could add more expedited treatment options to the armamentarium for pediatric migraine.
Summary There is increasing variety in the abortive treatment of pediatric migraine, but continued research is necessary for
validation of these approaches.
antagonists, diphenhydramine, valproic acid (VPA), magne- prochlorperazine achieved treatment success [11]. Although
sium, and dihydroergotamine (DHE) for the treatment of pe- this study suggests that prochlorperazine is superior to
diatric migraine [3, 8, 9•], but only a single article has studied ketorolac, these medications are frequently used together in
the effect on outcomes before and after protocol implementa- clinical practice rather than in isolation.
tion [9•]. Leung et al. describes a cohort of 165 patients prior
to and 87 patients after implementation, and they demonstrat- Dopamine Receptor Antagonists
ed a decrease in absolute pain score (6.9 vs 5.3, p ≤ 0.001),
decrease in length of stay (4.4 vs 5.3 h; p = 0.008), and de- Dopamine receptor antagonists (DRAs) are also a common
crease in admission rates (3% vs 32%, p ≤ 0.001) [9•]. In this class of medication used in the abortive treatment of migraine
article, we will describe the latest evidence of specific treat- as they have both analgesic and anti-nausea properties.
ments of migraine in the emergency department and inpatient Frequency of use in the pediatric ED and inpatient setting is
settings. 39–50% [2, 12] and 67% [10], respectively.
There have been several studies in recent years investigat-
ing the use of DRAs. Bachur et al. is a multi-center retrospec-
Case Presentation tive study of 32,124 children with migraine seen in pediatric
academic EDs from 2009 to 2012 that investigates the vari-
Patient is a 14-year-old female (47 kg) with migraine without ability in abortive treatment. 50% of patients received a DRA.
aura who presented to the emergency department for 3 days of Specifically, 48% received metoclopramide, 47% received
headache, described as an 8 out of 10 pulsating left prochlorperazine, and 5% received promethazine. These med-
frontotemporal headache associated with nausea, photopho- ications were most commonly used in combination rather than
bia, and phonophobia. She denies vision changes, paresthe- in isolation. The use of metoclopramide was associated with a
sias, or weakness. There is not a positional component. Prior 31% increased odds of return visit within 3 days when com-
to presenting to the ED, she administered rizatriptan 10 mg pared with prochlorperazine. This was not seen in
and ibuprofen 400 mg followed by a repeat dose of rizatriptan promethazine [2].
10 mg 2 h later. Although this regimen had previously aborted Sheridan et al. is a single-center retrospective study inves-
her migraines, this time it reduced her headache from a 9 to 8 tigating the efficacy of various DRAs in conjunction with an
out of 10. NSAID in 67 pediatric ED visits for 57 unique patients. The
choice of DRA was at the discretion of the treating physician,
and the rate of use for each was 40% prochlorperazine, 34%
Treatment metoclopramide, and 25% promethazine. The use of diphen-
hydramine was also at the discretion of the treating physician
Analgesics and was used in 89% of prochlorperazine cohort, 74% of
metoclopramide cohort, and 65% of promethazine cohort.
Non-opioid analgesics are the most common medication used Treatment failure was seen in 9% for prochlorperazine, 25%
in the emergency department for the treatment of migraine. for metoclopramide, and 43% for promethazine. In compari-
Bachur et al. report that 66% of patients receive this type of son with patients receiving prochlorperazine, the use of
medication in the ED [2]. In the inpatient setting, non-steroidal promethazine was associated with an 11 times increased odds
anti-inflammatory agents (NSAID) are 4th most common of treatment failure (p = 0.01) and decreased absolute pain
medication and are given to 43% of patients [10]. These med- reduction by 2.2 (p = 0.018). These outcomes were not statis-
ications can be used as monotherapy for patients with milder tically significant between prochlorperazine and
headaches or in combination with other classes of medications metoclopramide [4]. This study did not control for diphenhy-
for more severe headaches [3]. dramine, so it is unclear if its use contributed to efficacy.
Brousseau et al. explored the efficacy of intravenous (IV) Kabbouche et al. describe a cohort of 20 patients with mi-
fluids in conjunction with either ketorolac or prochlorperazine graine who presented to the ED and received treatment with
in a randomized, double-blinded 2-center trial of 62 children. prochlorperazine and IV hydration. At 1-h post-infusion, 90%
They demonstrated treatment success, defined as > 50% re- (18/20) of patients had an improved pain score with absolute
duction in pain score within 60 min, for 55% of patients re- mean pain reduction of 8.4 to 1.6 (p < 0.0001), and 60% (12/
ceiving ketorolac with a 31% recurrence within 48 h. 20) achieved headache freedom. At 3 h post infusion, 95%
Prochlorperazine demonstrated 85% treatment success and (19/20) of patients experienced a ≥ 50% reduction with 65%
27% recurrence within 48 h. For patients who failed the initial (13/20) achieving headache freedom. At 24 h follow-up, 90%
treatment, they were allowed to cross over to the other study (18/20) had achieved headache freedom [1]. The authors do
arm. 4/4 (100%) that crossed over to ketorolac achieved treat- not comment on if additional treatments were given post-dis-
ment success, and 8/12 (66%) that crossed over to charge, so it is unclear if additional medications and/or time
Curr Neurol Neurosci Rep (2020) 20: 15 Page 3 of 6 15
Dihydroergotamine Conclusion
Dihydroergotamine (DHE) is a potent vasoconstrictor due to This paper is a review of recent literature on the abortive
agonist effect at serotonin receptors, primarily 5HT1D. The first treatment of pediatric migraine in the emergency department
pediatric study for use of DHE was by Linder [33] in 1994; and inpatient settings, and there are several notable recent
however, continued research in the pediatric population has advances. Treatment protocols in the ED can improve out-
been limited. Variety in the initial and incremental dosing of comes by decreasing pain scores more efficiently and
DHE and type of access exists [3, 33, 34] in the published DHE preventing admissions. Continuous infusion is a novel ap-
protocols, but in general, the medication is administered every proach to treatment with VPA. Ketamine, propofol, and pe-
8 h, making it more appropriate for inpatient treatment. Rates of ripheral nerve blocks have the potential to be quicker treat-
use for inpatient encounters vary from 3 to 59% [2, 10]. ments than multi-day admission for dihydroergotamine. Two
Kabbouche et al. described a cohort of 32 patients who shortcomings of current literature is the focus on comparing
were admitted for IV DHE treatment of pediatric migraine. medications in isolation as they are rarely used that way and
Treatment success, defined as headache freedom at discharge, treatment success is only rarely defined as headache freedom.
was achieved in 74% of patients. It was noted that a significant Randomized control trials continue to be rare in this patient
decrease in headache pain occurred by dose 5 for most pa- population but are necessary to confirm if these treatment
tients, but that 67% required 12–13 doses before achieving regimens are effective.
headache freedom. Mean total dose administered was 7 mg,
and the average length of stay was 2.96 days. Treatment was Compliance with Ethical Standards
discontinued for 2 (6%) patients due to side effects [34].
Nelson et al. described a cohort of 124 unique patients with Conflict of Interest The authors declare that they have no conflict of
interest.
145 admissions for IV DHE treatment of migraine with use of
Linder protocol. Although 63% of patients had improvement in
Human and Animal Rights and Informed Consent This article does not
their headache, only 21% had complete resolution of pain. The contain any studies with human or animal subjects performed by any of
average number of doses administered for responders was 8.3, the authors.
while the non-responders received 7.2 doses (p = 0.002).
Duration of headache and use of prophylactic medication was
not statistically significant between the responders and non-re-
sponders, but the presence of a comorbid diagnosis, which anx- References
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1029–33. https://doi.org/10.1007/s10072-019-03766-x. tional claims in published maps and institutional affiliations.