Pediatric Headache
Pediatric Headache
Headache is one of the most common presentations to the pediatrics ER. Most of the time, one can ferret out who has tumor, bleed, or other serious secondary headache disorder from those with exacerbation of migraine or chronic daily headache. We therefore do not advocate routine ER imaging for those patients at low risk for secondary headache when they present.
There have been multiple papers describing successful approaches to treatment of status migraine in both the emergency setting, as well as the inpatient setting. Careful sequential use of medications used in the adult setting has been tried in children without a systemic prospective study. In patients naïve to triptans, triptans may serve as good first-line agents after analgesics. As with adults who utilize the ER for their headache exacerbations, pediatric headache experts have shied away from the prescribing of narcotics. Judicial use of Intravenous fluids, NSAIDs, dopaminergic agents, magnesium, valproate, and Dihydroergotamine (DHE) have been used successfully. Steroids are used as anti-inflammatory agents, and their roles in the ER settting have been summarized well for adults.
There is much experience treating adults as inpatients. There is one long-term inpatient unit at Cleveland Clinic where children and adolescents with chronic headache are shown a multidisciplinary approach. Programs in Michigan, Chicago, and Philadelphia incorporate teens into their adult inpatient headache units on a regular basis. Criteria to enter these units mirror those in the adult literature.
In the future, we would like to see a more rigorous approach with prospective trials of both individual agents and cocktails to look for safety, efficacy, and ER efficiency. What role does each of the components in a sequential cocktail have? Do steroids help? What about magnesium? Does DHE early in the pathway get people out quicker? What about IV valproate? Should youngsters be sent home on steroids and/or long-acting triptans? How different is treating status migraine in an episodic migraineur compared with a patient with chronic daily headache and acute exacerbation? Should the approach be different? Does frequent ER use predict debilitation as an adult?
ER and Inpatient Management
What We Know
Headache is one of the most common presentations to the pediatrics ER. Most of the time, one can ferret out who has tumor, bleed, or other serious secondary headache disorder from those with exacerbation of migraine or chronic daily headache. We therefore do not advocate routine ER imaging for those patients at low risk for secondary headache when they present.
There have been multiple papers describing successful approaches to treatment of status migraine in both the emergency setting, as well as the inpatient setting. Careful sequential use of medications used in the adult setting has been tried in children without a systemic prospective study. In patients naïve to triptans, triptans may serve as good first-line agents after analgesics. As with adults who utilize the ER for their headache exacerbations, pediatric headache experts have shied away from the prescribing of narcotics. Judicial use of Intravenous fluids, NSAIDs, dopaminergic agents, magnesium, valproate, and Dihydroergotamine (DHE) have been used successfully. Steroids are used as anti-inflammatory agents, and their roles in the ER settting have been summarized well for adults.
There is much experience treating adults as inpatients. There is one long-term inpatient unit at Cleveland Clinic where children and adolescents with chronic headache are shown a multidisciplinary approach. Programs in Michigan, Chicago, and Philadelphia incorporate teens into their adult inpatient headache units on a regular basis. Criteria to enter these units mirror those in the adult literature.
What We Would Like to Know
In the future, we would like to see a more rigorous approach with prospective trials of both individual agents and cocktails to look for safety, efficacy, and ER efficiency. What role does each of the components in a sequential cocktail have? Do steroids help? What about magnesium? Does DHE early in the pathway get people out quicker? What about IV valproate? Should youngsters be sent home on steroids and/or long-acting triptans? How different is treating status migraine in an episodic migraineur compared with a patient with chronic daily headache and acute exacerbation? Should the approach be different? Does frequent ER use predict debilitation as an adult?
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