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Treatment of Children With Migraine in the Emergency Department A Qualitative Systematic Review Benoit Bailey, MD, MSc, FRCPC*y and Barbara Cummins McManus, MD, FRCPC* from 3% to 10%.1Y3 A significant number of children present Objective: To evaluate which treatment could be effective in the to the emergency department either during the first episode, emergency department (ED) for children with migraine and statusmigrainosus, we carried out a qualitative systematic review of or for particularly severe episodes that do not respond to their randomized controlled trials (RCTs) that evaluated treatment that usual treatments. In fact, migraine represents 8% to 18% of could be used for those conditions.
all headaches seen in a pediatric emergency department.4,5 Methods: Databases (Cochrane Database of Systematic Reviews, Despite this, little attention has been given to the treatment Database of Abstracts of Reviews of Effects, Cochrane Controlled that could be administered to children who present to an Trials Register, MedLine, and EMBASE) were searched for RCTs emergency department with migraine headaches.
that evaluated treatment of migraine in children (G18 years of age).
Because adolescents have a high rate of success of Guidelines published on the subject were checked for missed placebo in the treatment of migraine, it may be difficult to references. Characteristics of the identified studies as well as extrapolate results for adult studies to children.6 The primary outcome (headache relief), other recognized primary out- Canadian Headache Society proposed adult guidelines in comes, and adverse events were abstracted. Quality of the RCTs was 1997 based on severity of the attack from mild to ultrasevere evaluated using the Jadad score.
attack.7 In 2004, the French Society for the Study of Results: Of the 14 trials included in the review, only 1 was Migraine Headache also proposed some guidelines for the performed in an ED after other treatments have failed. In that treatment of migraine in both adults and children.8 The situation, prochlorperazine was more effective than ketorolac in American Academy of Neurology also published in 2004 relieving pain at 1 hour. Other treatments were evaluated by pediatric practice parameters.9 They had previously issued in neurologists on their outpatients who started the studied drugs early 2000 practice parameters in adults.10 However, none of these at the beginning of the migraine without previous treatment. In that guidelines were for children who presented to the emergency situation, ibuprofen (n = 3) and acetaminophen (n = 1) were better department. Similarly, a recent systematic review11 or other than placebo for pain relief. The efficacy of intranasal sumatriptan reviews on migraine treatment in children do not specifically (n = 4), oral rizatriptan (n = 3), and oral zolmitriptan (n = 2) for pain address the question of emergency department treatment.12Y15 relief was unclear. Oral sumatriptan (n = 1) and oral dihydroergot- Two recent reviews present most of the available therapies amine (n = 1) were not effective.
for the acute treatment of migraine that did not respond to Conclusions: There is a lack of studies addressing the question of outpatient management, but many more recent randomized treatment in the ED for children experiencing migraine. Although controlled trials (RCTs) were not mentioned especially other treatments were found effective in children with migraine, concerning the triptans.16,17 Thus, this lack of evidence- none was evaluated in the ED except prochlorperazine and based guidelines can explain the significant variation in practice observed in the management of children withmigraine seen in 4 regional emergency departments in 1 Key Words: migraine, status migrainosus, adolescent Migraine headaches are extremely common during child- Thus, to evaluate which treatment for children with hood and adolescence. The reported prevalence ranges migraine and status migrainosus could be effective in theemergency department, we carried out a qualitative system-atic review of the literature in search of RTCs that evaluatedtreatment that could be used in that setting.
*Divisions of Emergency Medicine and yClinical Pharmacology and Toxicology, Department of Pediatrics, Centre Hospitalier Universitaire Ste-Justine, Montre´al, Quebec, Canada.
Address correspondence and reprint requests to Benoit Bailey, MD, MSc, The literature was searched for potential studies using FRCPC, Department of Pediatrics, CHU Ste-Justine, 3175 Chemin de la different strategies with Ovid. Systematic reviews were first Coˆte-Ste-Catherine, Montre´al, Quebec, Canada H3T 1C5. E-mail: searched in the Cochrane Database of Systematic Reviews, second quarter of 2007 (performed February 2, 2007 and Copyright * 2008 by Lippincott Williams & WilkinsISSN: 0749-5161/08/2405-0321 updated June 22, 2007), and the Database of Abstracts of Pediatric Emergency Care
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Pediatric Emergency Care
Volume 24, Number 5, May 2008 Reviews of Effects, second quarter of 2007 (performed systematic reviews, guidelines, or other recent reviews on the February 2, 2007 and updated June 22, 2007). These subject.7Y14,17,19Y23 No attempts were made to obtain unpub- databases were searched using the predefined keywords: lished studies.
migraine or headache and children. The Cochrane ControlledTrials Register, second quarter of 2007 (performed February 2, 2007 and updated June 22, 2007), was also searched for For this qualitative systematic review, only RTCs were possible RTCs using the same strategies. The MedLine 1950 included because of the usual high rate of success of placebo to June 2007 week 2 (performed February 5, 2007 and in the treatment of migraine particularly in adolescents.6 updated June 22, 2007) database was searched using the Thus, studies were included for review if they were RTCs of predefined strategies: (1) exp randomized controlled trials/; a medication for the treatment of acute migraine attacks in (2) Brandomized controlled trial[.pt.; (3) Bcontrolled clinical children (G18 years of age) regardless of the setting trial[.pt.; (4) (random$ or placebo$).ti,ab,sh.; (5) ((singl$ or departmentYinpatient or neurology clinicY double$ or triple$ or treble$) and (blind$ or mask$)).tw,sh.; outpatient). Studies were excluded if they were not RTC, (6) or/1Y5; (7) (animals not humans).sh.; (8) 6 not 7; (9) exp or if they evaluated a medication used for prophylaxis.
Migraine Disorders or headache/; (10) limit 9 to Ball adult (19plus years)[; (11) limit 9 to Ball child (0 to 18 years)[; (12) Data Extraction and Methodological Quality 11 not 10; and (13) 8 and 12. The EMBASE 1980 to 2007 Data of all included studies were abstracted in duplicate week 25 (performed February 5, 2007 and updated June 22, using a predefined table. Data extraction was done for name 2007) database was also searched using the predefined of author and year of publication, type of study, setting, how strategies: (1) exp randomized controlled trials/; (2) (random$ the migraine diagnosis was made, inclusion and exclusion or placebo$).ti,ab,sh.; (3) ((singl$ or double$ or triple$ or criteria, age range of the enrolled children, treatment treble$) and (blind$ or mask$)).tw,sh.; (4) controlled clinical evaluated, the number of patients enrolled, what type of trial$.tw,sh.; (5) or/1Y4; (6) (animal$ not human$).sh,hw.; (7) measurement tool was used, the primary outcome, rate of 5 not 6; (8) exp Migraine or headache/; (9) limit 8 to adult pain-free status at 2 hours, rate of recurrence, rate of use G18 to 64 years9; (10) limit 8 to (child Gunspecified age9 or of rescue medications, side effects, and author_s conclusion.
preschool child G1 to 6 years9 or school child G7 to 12 The Jadad score was used to evaluate the internal validity of years9 or adolescent G13 to 17 years9); (11) 10 not 9; and the studies, from 0 to 5, 5 being the study with the highest (12) 7 and 11. The references of all relevant studies were quality.24 We reported the primary outcome, usually pain cross-checked for other relevant articles as well as identified relief at 2 hours. When this outcome was not the primary FIGURE 1. Flow of randomized control trials identified in the systematic review by various databases searches.
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Volume 24, Number 5, May 2008 Treatment of Children With Migraine in ED TABLE 1. Level I Evidence Evaluating Acetaminophen, Ibuprofen, and Zolmitriptan for the Treatment of Migraine Attack inChildren Hamalainen et al27 Proposed revision IHSC42 Q2 attacks/mo lasting Q2 hPrevious medications not effectivePatients on prophylaxis excluded APAP PO 15 mg /kg IBU PO 200 or 400 mg N (enrolled/analyzed) 106/66 5-face scale (severe to none) 4-point scale (severe to none) 4-point scale (none to severe) , in pain by Q2 grade at 2 h , in pain from severe or moderate , in pain from severe or moderate if initial grade Q 3 to mild or none at 2 h to mild or none at 2 h APAP vs. P: OR 2.0 (0.9, 4.3) IBU vs. P: 34/45 vs. 21/39, IBU vs. P: 20/29 vs. 8/29, P G 0.05 IBU vs. P: OR 2.9 (1.0, 8.1) ZOL vs. P: 18/29 vs. 8/29, P G 0.05 APAP vs. IBU: 0.7 (0.4, 1.1)* IBU vs. ZOL: 20/29 vs. 18/29, NS APAP vs. P: OR 2.0 (0.9, 4.3) IBU vs. P: 20/45 vs. 10/39, IBU vs. P: 14/29 vs. 2/29, P G 0.01 IBU vs. P: OR 3.5 (1.0, 11.9) ZOL vs. P: 13/29 vs. 2/29, P G 0.01 IBU vs. APAP: OR 2.2 (1.1, 40) IBU vs. ZOL:14/29 vs. 13/29, NS APAP vs. P: 0/16 vs. 1/12, NS IBU vs. P: 8/45 vs. 14/39, IBU vs. P: 2/20 vs. 1/8, NS IBU vs. P: 1/24 vs. 1/12, NS ZOL vs. P: 4/18 vs. 1/8, NS APAP vs. IBU: 0/16 vs. 1/24, NS IBU vs. ZOL: 2/20 vs. 4/18, NS APAP vs. P: 8/78 vs. 18/78, NS IBU vs. P: 1/45 vs. 15/39, IBU vs. P: 5/29 vs. 8/29, NS IBU: 13/80 vs. 18/78, NS ZOL vs. P: 2/29 vs. 8/29, P G 0.05 APAP vs. IBU: 8/78 vs. 13/80, NS IBU vs. ZOL: 5/29 vs. 2/29, NS More adverse effects of ZOL vs. P Authors' conclusion APAP and IBU are effective ZOL and IBU are effective IBU gives best relief (see comments) ZOL has similar efficacy Intent to treat analysis was performed More patients in IBU were Low placebo response rate with a different outcome (any , in receiving prophylactic pain), in that situation in both treatment. IBU dose APAP and IBU were better than P, and there was no differencebetween APAP and IBU *Estimation from the figure.
DBR indicates double-blind randomized; XOver, crossover; IHSC, International Headache Society Criteria; APAP, acetaminophen; IBU, ibuprofen; P, placebo; ZOL, zolmitriptan; N, number of patients enrolled; NR, not reported; NS, nonsignificant; OR (95% CI), odds ratio and its 95% confidence interval.
outcome, we abstracted it to facilitate comparison as trials chosen by the same subcommittee were sustained pain- suggested by the International Headache Society Clinical free defined as pain-free within 2 hours with no use of rescue Trial Subcommittee.25 The 2 important outcomes of migraine medication, and recurrence within 48 hours were also * 2008 Lippincott Williams & Wilkins Copyright @ 2008 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
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Volume 24, Number 5, May 2008 TABLE 2. Level I Evidence Evaluating Intranasal Sumatriptan for the Treatment of Migraine Attack in Children Ueberall and Wenzel30 Neurologic clinic 2Y8 moderate-to-severe 1Y8 moderate-to-severe attacks/mo  2 mo attacks/mo  2 mo Resistant to common Failed Q1 medication(s) No acute medications from 6 h before and upto 1 h after study drug Patients on prophylaxis Prior no response to Patients on prophylaxis SUM IN 5 or 10 mg , in pain of severe or , in pain from severe or , in pain of severe or , in pain from severe or moderate to mild or moderate by 2 grade moderate to mild or 20 vs. P: 74/118 vs.
SUM vs. P: 53/83 vs.
20 vs. P: 144/237 vs.
vs. 6/14, P = 0.031 69/131, P = 0.059 127/244, P = 0.087 10 vs. P: 85/133 vs.
5 vs. P: 132/250 vs.
5 vs. P: 84/128 vs.
20 vs. P: 161/237 vs.
142/244, P = 0.025 5 vs. P: 158/250 vs.
20 vs. P: 42/118 vs.
SUM vs. P: 26/83 vs.
20 vs. P: 104/237 vs.
vs. 2/14, P = 0.016 73/244, P G 0.001 10 vs. P: 45/133 vs.
5 vs. P: 33/128 vs.
20 vs. P: 19/118 vs.
SUM vs. P: 4/83 vs.
20 vs. P: 57/237 vs.
10 vs. P: 27/133 vs.
5 vs. P: 58/250 vs.
5 vs. P: 23/128 vs.
(continued on next page) * 2008 Lippincott Williams & Wilkins Copyright @ 2008 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
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Volume 24, Number 5, May 2008 Treatment of Children With Migraine in ED TABLE 2. Continued SUM vs. P: 0/14 vs.
20 vs. P: 31/118 vs.
SUM vs. P: 29/83 vs.
20 vs. P: 97/237 vs.
120/244, P = 0.063 10 vs. P: 29/133 vs.
5 vs. P: 105/250 vs.
120/244, P = 0.119 5 vs. P: 27/128 vs.
More taste disturbance More taste disturbance More taste disturbance SUM IN is effective SUM IN is effective SUM may be beneficial to some adolescents Unusual results (low dose effective not higher dosagesfor primary outcome) *Estimation from the figure.
DBR indicates double-blind randomized; XOver, crossover; IHSC, International Headache Society Criteria; SUM, sumatriptan; P, placebo; APAP, aceta- minophen; NSAID, nonsteroidal anti-inflammatory drugs; N, number of patients enrolled; NS, nonsignificant.
abstracted.25 Comments on the various studies were made studies. The only comparative study with the triptans com- when deemed appropriate.
pared zolmitriptan against ibuprofen and placebo (Table 1).28 Another study evaluated oral dihydroergotamine (DHE) against a placebo (Table 4).38 Finally, 1 study Odds ratio was not calculated because for most of the compared intravenous ketorolac to intravenous prochlorper- studies, they were impossible to compute considering the azine (Table 4).39 crossover design of the study and the absence of raw data All studies, except one, were neurology clinic-based, presented in the articles. An attempt was made to contact the and children with migraine that fit the International Headache authors of these studies.
Society criteria (1988), its second edition (2004), or a A summary of the RCTs that evaluated efficacy of the proposed revision were treated initially with the study drug medications used to treat children with migraine was or the placebo at home.40Y42 The only study done in a produced for each important outcome recommended by the pediatric emergency department compared prochlorperazine International Headache Society Clinical Trial Subcommit- versus ketorolac in children that fit the Prensky and Sommer tee:25 pain relief, pain-free, recurrence, and need for rescue migraine criteria.39,43 Those patients were likely to have medications. Medications considered effective for the out- received other medications either at home or in the come were those where the RCTs showed consistent positive emergency department before being included in the study.39 results or where one RCT showed a positive result.
This was not the case in the other identified studies; the Medications not considered effective for the outcome were studied medications were used first and early after the those with RCTs that showed consistent negative results or migraine had started.
with one RCT that showed a negative result. Medications that The quality of the trials was generally good as were found inconsistent for the outcome were those that had evaluated by the Jadad score, but most had large confidence RCTs that showed both positive and negative results.
interval. There was an important number of lost to follow-upin most studies. Two studies29,38 evaluated responses to other treatments in a population initially used for another.27 Most The comprehensive search identified a limited number studies had a priori power calculation: only 2 did not.26,30 of relevant RTCs (Fig. 1).
One study evaluated ibuprofen against a placebo,26 another evaluated both acetaminophen and ibuprofen against Like all other systematic reviews or meta-analyses, the a placebo,27 and another compared ibuprofen and zolmitrip- quality of this qualitative systematic review is limited by the tan, a triptan, against a placebo.28 Table 1 summarizes these quantity and quality of the available evidence. Considering that we wanted to evaluate which treatment for children with Several studies evaluated triptans alone; 1 evaluated migraine and status migrainosus would be effective in the oral sumatriptan against a placebo,29 4 evaluated intranasal emergency department, it was striking to find that in all but 1 sumatriptan against a placebo,30Y33 3 evaluated oral riza- study, the patients were treated at home. What does this say triptan against a placebo,34Y36 and 1 evaluated oral zolmi- for patients seen in the emergency department? In patients triptan against a placebo.37 Tables 2 and 3 summarize the 9 studied at home, the studied medication was the first agent * 2008 Lippincott Williams & Wilkins Copyright @ 2008 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
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Volume 24, Number 5, May 2008 TABLE 3. Level I Evidence Evaluating Oral Triptans for the Treatment of Migraine Attack in Children Hamalainen et al29 Q1 and e8 attacks/ Q1 and e8 attacks/ Q2 and e10 attacks/ Moderate or severe Previous unsatisfactory response to acetamin- prophylaxis excluded RIZ PO 5 or 10 mg RIZ PO 5 or 10 mgP PO moderate (Q3) by at least 2 grade at 2 h RIZ vs. P: 159/233 ZOL vs. P: 263/480 RIZ vs. P: 71/96 vs.
2nd RIZ vs. P: 70/96 vs. 35/96, P G 0.001 RIZ vs. P: 98/148 Pain-free at 2 h SUM vs. P: 5/23 RIZ vs. P: 48/148 RIZ vs. P: 91/233 vs.
ZOL vs. P: 107/480 RIZ vs. P: 34/96 vs.
75/240, P = 0.053 2nd RIZ vs. P: 30/96 vs. 17/96, P = 0.037 RIZ vs. P: 84/233 RIZ vs. P: 17/96 vs.
2nd RIZ vs. P: 21/96 vs. 38/96, P = 0.017 More adverse events More adverse events Similar efficacy of RIZ PO is effective High rate of responders High rate of responders Same results with DBR indicates double-blind randomized; XOver, crossover; IHSC, International Headache Society Criteria; SUM, sumatriptan; RIZ, rizatriptan; ZOL, zolmitriptan; P, placebo; NSAID, nonsteroidal anti-inflammatory drugs; N, number of patients enrolled; NR, not reported; NS, nonsignificant.
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Volume 24, Number 5, May 2008 Treatment of Children With Migraine in ED TABLE 4. Level I Evidence Evaluating DHE, Ketorolac, and Prochlorperazine for the Treatment of Migraine Attack in Children Hamalainen et al38 Brousseau et al39 Prensky and Sommer criteria43 Enrolled when decision to treat IV Patients on prophylaxis excludedMost patients participated previously in a study comparing APAP and IBU to P27 PRO IV 0.15 mg/kg DHE PO 40 2g/kgP PO N (enrolled/analyzed) 5-point scale (severe to none) 9-face pain scale (1-9) , of severe or moderate by 2 grade at 2 h , by 50% or complete relief at 1 h DHE vs. P: 7/12 vs. 2/12, P = 0.06 PRO vs. KET: 28/33 vs. 13/29, $30% (95% CI: 8, 52) DHE vs. P: 5/12 vs. 0/12, NR DHE vs. P: 2/5 vs. 0/0, NR PRO vs. KET: 7/26 vs. 4/13, $ j4% (95% CI: j34, 27) Use of rescue medications DHE vs. P: 6/12 vs. 8/13, NR Author's conclusion DHE PO may be useful PRO IV is superior to KET IV Unusual low rate of responders in placebo group Only ED-based studyMost children received medications before ED visit, but there is no report of medications used beforestudy in the ED DBR indicates double-blind randomized; XOver, crossover; PED, pediatric emergency department; IHSC, International Headache Society Criteria; KET, ketorolac; P, placebo; PRO, prochlorperazine; APAP, acetaminophen; IBU, ibuprofen; N, number of patients enrolled; NR, not reported; ED, emergencydepartment.
used for a migraine attack and is likely to have been used they wish and expect to be pain-free after a treatment.25 early after the onset of the headache as per the investigators_ Other important outcomes that need to be evaluated are use instructions. In patients seen in an emergency department, of rescue medication 2 hours after the intervention and some, if not most, patients have tried other medications that recurrence defined as any severity returns within 48 hours.25 were probably ineffective, and again, some, if not most, This is why we reported all 4 relevant outcomes.
patients were seen well after the onset of the migraine. It is Half of the identified RCTs were crossover trials. None unclear if a medication found effective at home can also be of them provided raw data preventing the calculation of odds effective when another treatment has previously failed. Thus, ratio when not reported and adequate pooling of the data. We any conclusions for treatment in an emergency department chose not to analyze the crossover trials as parallel trials like need to take this limitation into account.
others have done.11 This could have led to a debatable Furthermore, interpretation of the results is somewhat conclusion considering the inconsistent results for some complicated by the outcomes measured. Most studies used pain relief measured 2 hours after the intervention as theirprimary outcome. This may not be the best outcome formigraine trials according to the International Headache Society Clinical Trials Subcommittee.25 Instead, they recom- Only a limited number of medications proposed in the mend pain-free at 2 hours before any rescue medication as guidelines of the Canadian Headache Society, the French the primary measure of efficacy because patients indicate that Society for the Study of Migraine Headache, and the * 2008 Lippincott Williams & Wilkins Copyright @ 2008 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
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Volume 24, Number 5, May 2008 American Academy of Neurology have been studied by of its very rapid onset of action compared with the oral RCTs in children.7Y10 Not surprisingly, the more recently formulation (15 minutes compared with 30 to 60 minutes for available medications, the triptans, are the most widely oral sumatriptan).44 Furthermore, migraine-associated gastric stasis has also been suggested to explain the difference of From the studies that evaluated acetaminophen and efficacy of oral triptans in children compared with adults.44 ibuprofen, it seems that ibuprofen was effective as initial This hypothesis seems to be incorrect because acetamino- treatment for pain relief (Table 5).26Y28 Acetaminophen also phen, ibuprofen, and zolmitriptan administered orally were seems to be effective for the same outcome, although the found to be effective in children.26Y28 results are not as clear as with ibuprofen because of the way Oral DHE did not seem to be effective but was the analysis was done in the study (intent-to-treat analysis not evaluated in only 12 children (Table 5).38 In any case, used to report the primary outcome).27 When the results were nausea associated with DHE could limit this option even if it analyzed on an intent-to-treat basis, acetaminophen was had been effective.7 found effective for pain relief but not pain-free. Neither Intravenous prochlorperazine was the only treatment acetaminophen nor ibuprofen prevented recurrence.26,27 that was evaluated and found effective for pain relief as Ibuprofen decreased the need for rescue medications in one treatment in the emergency department after other migraine trial,26 but not in the others.27,28 Acetaminophen did not treatment had failed at home (Table 5).39 If we include decrease the need for rescue medications (Table 5).27 patients treated with prochlorperazine after ketorolac had Several authors have concluded that oral triptans are failed, the success of prochlorperazine was 85% (51/60). This not as effective in children as they are in adults.19,44 was impressive considering that the attacks were present for a However, nasal sumatriptan may be effective.19,44 Most of median of 24 to 25 hours and that more than 80% of patients the studies that evaluated oral sumatriptan, oral rizatriptan, received pain medications before the visit to the emergency and oral zolmitriptan found that these medications were not department including 32% to 35% migraine-specific medi- effective for pain relief (Table 5).29,34,35,37 The exceptions are cations. The rate of success with ketorolac (55%) was close 2 recent studies that found oral rizatriptan and oral to what might be expected with placebo (30%Y50% response zolmitriptan better than placebo for pain relief, pain-free, rate), although the possibility that ketorolac was effective, and need for rescue medications.28,36 The difference may be keeping in mind the severity of the migraine attack treated in explained by high placebo response rate in previous studies this study, cannot be excluded. We do not know if with both medications. Interestingly, zolmitriptan was as prochlorperazine is effective for the outcome pain-free or to effective for pain relief, pain-free, and need for rescue decrease the need for rescue medications. However, pro- medications but not better than ibuprofen in the only chlorperazine did not prevent recurrence (Table 5).
comparative study involving the triptans.28 None of the oral From all this, it is difficult to draw conclusion for triptans prevented recurrence (Table 5). Intranasal sumatrip- emergency department treatment of mild or moderate attack tan gave inconsistent results in 4 studies for pain relief, pain- in children. In that situation, acetaminophen or ibuprofen free, and the need for rescue medications (Table 5). However, may be used to relieve pain, but patients are likely not to none decreased recurrence (Table 5). It has been suggested become pain-free (Table 5). In these situations, it is unclear that nasal sumatriptan may be an effective treatment because if any medications will be effective if the first one was TABLE 5. Summary of the Efficacy of the Medications Used to Treat Children With Migraine Need for Rescue Medications Acetaminophen (n = 1) Ibuprofen (n = 3) Rizatriptan (n = 3) Sumatriptan (n = 1) Zolmitriptan (n = 2) Intranasal medication Sumatriptan (n = 4) Intravenous medications Prochlorperazine (n = 1) Ketorolac (n = 1)* *Used as a comparative agent against prochlorperazine.
+ indicates studies showing consistent positive results or a study showing positive result; j, studies showing consistent negative results or a study showing negative result; +/j, studies showing inconsistent results; ?, not evaluated.
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Volume 24, Number 5, May 2008 Treatment of Children With Migraine in ED ineffective. Intranasal sumatriptan may be considered, but 9. Lewis D, Ashwal A, Hershey A, et al. Practice parameters: Pharmaco- because of the discrepancy in the different studies, it is logical treatment of migraine headache in children and adolescents.
Neurology. 2004;63:2215Y2224.
unclear if it is really effective for pain relief. The place of oral 10. Silberstein S. Practice parameter: Evidence-based guidelines for triptans in the emergency department is unclear, as one study migraine headache (an evidence-based-review). Neurology. 2000;6: found oral zolmitriptan no better than ibuprofen. For severe or ultrasevere attacks, intravenous prochlorperazine seems to 11. Damen L, Bruijn J, Verhagen A, et al. Symptomatic treatment of be the medication of choice in the emergency department migraine in children: a systematic review of medication trials. Pediatrics.
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with a very good chance of success in relieving pain despite 12. Hamalainen ML. Migraine in children and adolescents: a guide to drug previous failure with other treatment (Table 5). The rate of treatment. CNS Drugs. 2006;20:813Y820.
adverse reactions, especially of extrapyramidal symptoms, is 13. D_Amico D, Moshiano F, Usai S, et al. Treatment strategies in the acute unknown with the use of prochlorperazine in children. From therapy of migraine: stratified care and early intervention. Neurol Sci.
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a cohort of children treated with intravenous prochlorperazine 14. Cuvellier J, Joriot S, Auvin S, et al. Pharmacologic treatment of acute who received diphenhydramine as prophylaxis of extrapy- migraine attack in children. Arch Pediatr. 2004;12:316Y325.
ramidal symptoms published only as an abstract thus far, 6 15. Lewis DW. Pediatric migraine. Pediatr Rev. 2007;28:43Y52.
(12%) of 51 patients developed akathisia within 24 hours of 16. Kabbouche MA, Vockell AL, LeCates SL, et al. Tolerability and discharge.45 This will need to be evaluated in the future.
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Pediatrics. 2001;107:e62.
Because prochlorperazine do not prevent recurrence, patients 17. Bulloch B, Teneibein M. Emergency department management of should be discharged with additional analgesics.
pediatric migraine. Pediatr Emerg Care. 2000;16:196Y201.
No study has evaluated whether or not there are any 18. Richer L, Graham L, Klassen TP, et al. Emergency department medications or any dosage schedules better than others to management of acute migraine in children in Canada: a practicevariation study. Headache. 2007;47:703Y710.
prevent recurrence in the next few hours or days after 19. Major PW, Grubisa HS, Thie NM. Triptans for treatment of acute discharge from the emergency department. In the study by pediatric migraine: a systematic literature review. Pediatr Neurol.
Brousseau et al,39 patients were discharged on naproxen as needed for the next 48 hours after receiving either pro- 20. Smith E, Cantrill S, Dalsey W, et al. Clinical policy for the initial chlorperazine or ketorolac. Recurrence rate was 27% to 31% approach to adolescents and adults presenting to the emergency depart-ment with a chief complaint of headache. Ann Emerg Med.
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