ED Guidelines for Evaluation/Treatment of the Child with Migraine Headache

Admit Neurology or Discharge

Admit Neurology Discharge
Patients with persistence of significant headache after 2 interventions who could benefit from further inpatient management should be admitted.

Patients who have had adequate relief of their headache or have continued headache but are unlikely to benefit from further inpatient management and are able to tolerate oral fluids can be discharged home with one of the following care plans:

Ibuprofen/Ketorolac responsive

  • Ibuprofen 10 mg/kg PO, max 800 mg, q 6 hours prn
  • Patients requiring NSAID q 6 hours around the clock for > 48 hours require reevaluation

Metoclopramide responsive

  • Provide a prescription for 2 doses of metoclopramide for home use.
  • May give first dose at home 6 hours following the ED dose.
  • An additional dose may be given in 6 hours after the first home dose if the headache continues. (dose 0.2 mg/kg PO, max 10 mg <12 y/o, max 20 mg ≥ 12 y/o)
  • Patients should be instructed to use ibuprofen as described above.

Methylprednisolone responsive

  • Provide a prescription for a medrol dose pack.
  • Consider prescription for oral zantac while on steroids.
  • Instruct the patient that it should be started the following day.
  • Patients should be instructed to use ibuprofen as described above.

Valproate responsive

  • Discuss home dosing with neurology.
  • Check hepatic panel prior to beginning home regimen of valproate
  • Patients should be instructed to use ibuprofen as described above.

General

  • Instruct patient to drink a minimum of calculated maintenance fluids daily
  • Avoid caffeine-containing substances
  • Review use of Headache Diary
  • Follow-up with PMD

Headache Prophylactic Medication

  • Discuss indications for prophylactic medication and medication choice with Neurology.
  • Consider discharge with prescription for prophylactic medication
    (1 month supply).
  • Neurology follow-up is required if prophylactic medication is started in the ED.

Indications for CHOP Neurology follow-up via Web Referral (2-4 weeks)

  • Unclear diagnosis
  • Not responsive to initial abortive therapies prescribed by PMD
  • Migraines occurring several times per month
  • If prophylaxis started in ED
  • Parental or PMD request