Management of Primary Headache in the Emergency Department and Inpatient Headache Unit
Introduction
Migraine in children has been underrecognized until the last decade. Disability from migraine in school age children may lead to failure in academic work and withdrawal from social activities. It can also lead to or exacerbate pre-existing depression in some cases.1, 2 Diagnosing and treating these primary headaches as early as possible with the most appropriate available therapies may prevent the headaches from evolving into chronic disabling ones.
It is to note that headache is the third leading cause of referral to a pediatric emergency department (ED). The most common etiology of headache presenting to the ED is viral infections with fever. Migraine headache is approximately one third of them (range: 18%-21%).3, 4 Serious neurological disorders such as meningitis, shunt malfunction, and hydrocephalus are diagnosed in 6.6% of these patients. In all these occasions the neurological examination is abnormal and further work up such as neuroimaging is recommended.5, 6
Section snippets
Evaluation and Management of Primary Headache in the ED
The initial evaluation of headache should emphasize on differentiating primary from secondary headaches. An adequate evaluation should consist of7:
- 1.
A detailed history of the presenting headache including onset, duration, description of the pain, severity of the pain, associated symptoms, frequency of the underlying headaches, medication use, drug abuse, medical history, and family history.
- 2.
A full general assessment including all vital signs, as well as a detailed neurological examination
Evaluation and Management of Primary Headache in an Inpatient Unit
Approximately 6%-7% of patients fail acute treatment in the ED. They are usually admitted for a 3- to 5-day stay and receive extensive parenteral treatment. A child should be admitted to the hospital for a primary headache when he or she is in status migrainosus or has a severe exacerbation of a chronic headache. The goal of inpatient treatment is to control a headache that is disabling to the child and has been unresponsive to other abortive therapy. In addition, during the hospital admission
Conclusion
Migraine headache can be debilitating. Aggressive management may prevent severe disability and failure at school if initiated early.
It is imperative to state that treatments available for acute migraine headache in children and adolescents are off label. Their use is widespread but double-blind placebo-controlled studies are still unavailable for this age group.
References (35)
- et al.
Evaluation and management of headache in the emergency department
Med Clin North Am
(2001) Headache in the pediatric emergency room
Seminar in Pediatric Neurology.
(2001)- et al.
Evaluation of the patient with nontraumatic headache: An evidence based approach
Emerg Med Clin North Am
(1999) - et al.
Randomized placebo-controlled evaluation of prochlorperazine versus metoclopramide for emergency department treatment of migraine headache
Ann Emer Med
(1995) - et al.
Treatment of pediatric migraine headaches: A randomized, double-blind trial of prochlorperazine versus ketorolac
Ann Emerg Med
(2004) - et al.
Intravenous sodium valproate versus prochlorperazine for the emergency department treatment of acute migraine headaches: A prospective, randomized, double-blind trial
Ann Emerg Med
(2003) - et al.
A comparative trial of three agents in the treatment of acute migraine headache
Ann Emerg Med
(1990) Migraine in school children
Acta Paediatr Scand
(1962)- et al.
School problems and other factors in childhood headache syndromes
J Learn Disabil
(1984) - et al.
The association between major depression and headache: Results of a longitudinal epidemiologic study in youth
J Child Adolesc Psychopharmacol
(1996)
Comprehensive pediatric headache examination
Pediatr Ann
Chlorpromazine for the treatment of migraine in a pediatric emergency department
Headache
Intravenous ketorolac versus intravenous prochlorperazine for the treatment of migraine headaches
Acad Emerg Med
A randomized trial of divalproex sodium extended-release tablets in migraine prophylaxis
Neurology
Intravenous valproate sodium (Depacon) aborts migraine rapidly: A preliminary report
Headache
Pharmacologic treatment of headache
Headache in Children and adolescents.
Cited by (6)
Clinical Feature: Migraine in Adolescents
2019, Journal for Nurse PractitionersCitation Excerpt :Children ages 10 to 12 years old initiate therapy with 0.2 mg, and adolescents older than 12 years receive a starting dose of 0.25 mg.10 There are several different protocols for administering IV DHE, but a single dose in the emergency department can provide effective resolution of status migrainosus.8 If unsuccessful with emergency room management, patients will need to transition to inpatient treatment.8
Acute Migraine Treatment
2021, CONTINUUM Lifelong Learning in NeurologyImaging of children with nontraumatic headaches
2018, American Journal of RoentgenologyTargeting the underestimated and underdiagnosed global problem of headache disorders
2017, Annals of Tropical Medicine and Public Health