Emergency Department and Inpatient Clinical Pathway for
Evaluation/Treatment of Children with Suspected Migraine Headache
- Related Pathways
Serious Secondary HA Symptoms
- Persistent confusion or altered consciousness
- Abnormal neurologic exam
- Seizures
- Severe thunderclap HA
- Increased intracranial pressure signs/symptoms
- Meningeal signs
- Consider
- Stroke Pathway
- Imaging
- Neurology Consult
- Pain Assessment
- Consider POC hCG as required for 2nd line medications
Team Assessment
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
- PO Rehydration
- PO NSAID + ODT Rizatriptan
- PO Metoclopramide
- IV NS bolus
- IV Ketorolac
- IV Metoclopramide
Valproic Acid, IV Once
Review indications for IN Ketamine, prior to admit decision, ED Only
Consider Admission
- Continue escalation pending admission
- Imaging, Laboratory Considerations
- Consider non-pharmacologic pain management consults
Discharge
- Discharge Criteria
- HA resolved, improved, or decreased to baseline
- HA not improved but unlikely to benefit from inpatient treatment
- Failed, defers, or not eligible for DHE
- DHE contraindications and medication interactions
- Review pain management with Neurology
- Discharge Instructions, Follow-up
- Discharge Medications
- Acute Treatment
- Consider naproxen and/or methylprednisolone bridge after discharge to prevent HA recurrence
- Preventative Treatment
Magnesium Sulfate, IV Once
Methylprednisolone, IV Once
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
- Consider levetiracetam or nerve block in hospital and post-discharge
- Review Findings Suggestive of Secondary HA, SNOOPY
- Imaging, Laboratory Considerations
Evidence
- Treatment of Pediatric Migraine Headaches: a Randomized, Double-Blind Trial of Prochlorperazine Versus Ketorolac
- Triptans in the Acute Migraine Management of Children and Adolescents: An Update
- The Efficacy of Different Triptans for the Treatment of Acute Headache in Pediatric Migraine: A Systematic Review
- Behavioral Interventions for Migraine Prevention: A Systematic Review and Meta-Analysis
- Intranasal Ketamine for Abortive Migraine Therapy in Pediatric Patients: A Single-Center Review
- Inpatient Treatment of Status Migraine with Dihydroergotamine in Children and Adolescents
Educational Media
- Pediatric Chronic Pain
- Primary Care Perspectives Podcast, Managing Pediatric Migraine Headaches in Primary Care
CHOP Programs
