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Migraine Headache Clinical Pathway – Emergency Department and Inpatient

Emergency Department and Inpatient Clinical Pathway for
Evaluation/Treatment of Children with Suspected Migraine Headache

Serious Secondary HA Symptoms

  • Persistent confusion or altered consciousness
  • Abnormal neurologic exam
  • Seizures
  • Severe thunderclap HA
  • Increased intracranial pressure signs/symptoms
  • Meningeal signs
 
 

ED Triage

  • Pain Assessment
  • Consider POC hCG as required for 2nd line medications
 
 
 
 

Consistent with Migraine HA
Review efficacy of previous treatments, modify protocol as indicated

 
 

Medication Escalation for Migraine

  • Initiate Non-Pharmacologic Therapies
  • Reassess for improvement 45–60 mins following medication
  • Proceed until adequate improvement in pain
  • Determine disposition
  • BHS Screen, SW Mental Assessment as indicated

Improved Pain

  • Resolution
  • Subjective improvement
  • Return to baseline HA
  • Functional improvement
  • Tolerating PO
  • Child preference
  • Not tolerating PO
  • Failed adequate PO doses at home
  • Prolonged HA > 24 hrs, affecting function
  • Child preference
 
 
 
 
 
 
 
 

Valproic Acid, IV Once

Review indications for IN Ketamine, prior to admit decision, ED Only

 
 

Consider Admission

Discharge

 
 
 
 
 
 

Dihydroergotamine (DHE) Inpatient Only

  • Continue ketorolac, metoclopramide, add diphenhydramine for metoclopramide side effects
  • Consider PO ubrogepant if not already given if DHE contraindicated or within 24 hrs of triptan
 
 
Not improved after 5 doses DHE

 

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