Pediatric emergency medicine trisk 2622 2622
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to use sumatriptan after a trial of analgesics in an older child, although older
children or adolescents with recurrent migraine and a history of successful
treatment with sumatriptan in the past may benefit from earlier use of this agent.
Triptans should not be administered to children with complicated migraines.
Ketorolac (Toradol), a nonsteroidal anti-inflammatory agent for parenteral use,
may be used when nausea or vomiting limits oral intake. A short course of a
narcotic analgesic such as oxycodone may rarely be needed if nonnarcotic agents
have failed, especially if the headache prevents sleep.
Dopamine receptor antagonists such as metoclopramide (Reglan),
prochlorperazine (Compazine), and promethazine (Phenergan) are commonly
used in the ED setting, especially in the presence of nausea and vomiting. These
agents have the potential to produce dystonic reactions; it is common to
prophylactically coadminister diphenhydramine. Because they have fewer side
effects, ondansetron (Zofran) and granisetron (Kytril) have also become first-line
agents in the treatment of nausea and vomiting associated with migraine
headaches. These medications, however, have not been studied as primary
treatment of migraine headaches. There is low-quality evidence supporting the
benefit of combined therapy with prochlorperazine, diphenhydramine, and
ketorolac administered parenterally along with a fluid bolus. This combination is
frequently used in an ED setting.
Ergot preparations act primarily as cerebral vasoconstrictors and are
specifically indicated for aborting acute migraine attacks. They are not typically
used as a first-line treatment because of the common side effects, including
nausea, vomiting, cramps, and distal paresthesias, all of which may intensify the
symptoms of migraine. Dihydroergotamine (DHE) is an injectable ergot
derivative. It can be given to older children and adolescents in an initial dose of
0.5 mg IM or IV (no milligram per kilogram dose has been established). The
initial dose of DHE may be repeated in 1 hour if necessary. Ergot preparations
should not be used concomitantly with triptans. Antiemetics may be useful to
control the nausea and vomiting that often occur after DHE administration.
Sodium valproate, used for migraine prophylaxis, has been effective in treating
migraine in case series, but no controlled efficacy data exist.
If migraines are frequent and severe, prophylactic treatment is possible. There
is low-quality evidence that cognitive behavior therapy in combination with
amitriptyline benefits adolescents and school age children with chronic migraine.
Many drugs have been used, but because some require close, serial examination
and have no effect on the acute attack, generally they should not be started in the
ED. Among the medications used for chronic suppressive therapy are
