Migraine Headache — Discharge Directions — Clinical Pathway: Emergency

Migraine Headache Clinical Pathway — Emergency Department

Discharge Directions

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 PO fluids can be discharged home with the following care plans:

Medication/Lifestyle Modification Discharge Education

If a patient has been responsive to a medication in the emergency department, consider discharge with a prescription of that medication, as described below.

Ibuprofen/Ketorolac
  • 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 re-evaluation
  • SE: stomach upset
Metoclopramide
  • Provide a prescription for 2 doses of Metoclopramide for home use.
    • 1st dose may be given 6 hours following the ED dose
    • Additional dose may be given in 6 hours after the first dose if the headache continues
  • Dose 0.2 mg/kg PO
  • Max: 10 mg
  • SE: sedation, restlessness, rare dystonic reaction (treat with Diphenhydramine)
Methylprednisolone
  • < 12 years: Discharge with 2 mg/kg/day with rapid taper over 5-6 days
  • ≥ 12 years: Provide a prescription for a Medrol dose pack
  • Do not give simultaneous NSAID
  • Start pack the day following the ED visit
  • SE: Increased appetite, stomach upset, mood changes, irritability insomnia
Valproic Acid
  • Discuss home dosing with neurology
    • 15 mg/kg, max 500 mg, at bedtime
    • SE: nausea, drowsiness, dizziness, vomiting, decreased appetite, tremors
    • Uncommon serious SE: liver dysfunction/failure, pancreatitis, teratogenesis, ovarian cysts
    • Consider checking hepatic panel before discharge
  • Neurology follow-up required (1-2 weeks), use ED expedited referral order in Migraine Discharge Smart Set
General Health Habits
  • Instruct patient to drink a minimum of calculated maintenance fluids daily
  • Avoid caffeine-containing substances
  • Review use of Headache Diary
  • SMART Habits: Stress importance of healthy behaviors and stress reduction strategies to reduce pain and prevent recurrence of headache
    • Sleep: At least 8 hours (teens need more), go to sleep and awaken around the same time
    • Meals: At least 3, don’t skip, drink plenty of fluids
    • Activity: Exercise is really effective for treating and preventing HA
    • Relaxation: Music, massage, compresses, breathing, yoga, meditation
    • Triggers: Recognize them, helpful to use the HA Diary
  • Follow up with PMD 2-4 weeks
Limitation on use of Acute medications
  • To prevent Medication Overuse Headache, also known as Rebound Headache, medications used for acute headache treatment (including over-the-counter and prescription) should be limited to < 10 days/month.
Headache Prophylactic Medication
  • Discuss indications for prophylactic medication and medication choice with Neurology
  • Consider discharge with prescription for prophylactic medication (1 month supply)
  • Enter expedited referral to Neurology for 2-4 weeks if medication is started
Other Indications for CHOP Neurology Follow-up
  • Unclear diagnosis
  • Not responsive to initial abortive therapies prescribed by PMD
  • Migraines occurring several times per month
  • Parental or PMD request
  • If urgent referral is medically necessary, please provide explanation in referral request