Management of Primary Headache in the Emergency Department and Inpatient Headache Unit

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Migraine is a chronic disorder with debilitating exacerbations throughout the lifetime of migraineurs. Children and adolescents are significantly affected. The prevalence of migraine in this age group is higher than predicted in the last decade. Fortunately, this chronic disease is getting more attention and recognition, and better treatments are now being offered to these patients. Different medications are available, mostly for the outpatient management of an attack and include the use of over-the-counter anti-inflammatory medications as well as prescribed medications like the triptans group. These therapies do sometime fail and the exacerbations can last days to weeks. Early aggressive intravenous treatment can be very effective in breaking the attack and allowing the child to be functional faster and sometimes may prevent chronification of an attack.

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.

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