BOSTON—Clinicians should weigh several key issues when diagnosing and treating pediatric patients with intractable headache in the emergency department, according to Marielle Kabbouche, MD. She reviewed those considerations, as well as recent research comparing current treatment options, at the 50th Annual Scientific Meeting of the American Headache Society.
Diagnosing Childhood Headache in the Emergency Department
First, it is important to know when to send a child to the emergency department, said Dr. Kabbouche, who is Assistant Professor of Pediatrics and Neurology at Cincinnati Children’s Hospital Medical Center. “We cannot send all children to the emergency department if they have a bad migraine. It’s a hassle for the parents, and it’s a hassle for the kids.”
She urged clinicians to ensure that children with a severe migraine are treating their headache as directed, so that they will be able to either recommend maximizing current outpatient treatment or determine whether an immediate admission to the emergency department is warranted.
“You have to ask [patients] if they took the right medication, if they took the right dose, and then you decide whether they need more aggressive treatment,” she noted.
If a patient’s headache is still unresponsive after trying all appropriate outpatient treatments, Dr. Kabbouche advised clinicians to refer the patient to the emergency department. She pointed out that the headache referral rate in the emergency department is approximately 1.3%; of this percentage, 6.6% have a serious neurologic disorder. Migraine is diagnosed correctly in 18% to 21% of children in the emergency department, but “there are a lot of gaps” in other diagnoses, she said. For example, migraine with and without aura has a 15% to 58% correct diagnosis rate, tension-type headache has a 4% to 29% rate, and nonspecific headache has a rate of 14% to 41%.
“[Since] there’s a big variation in the emergency department in diagnosing these kids, there’s a big variation in treating them, because they’re not being diagnosed appropriately,” said Dr. Kabbouche. “We really have to have the right diagnosis before we can initiate therapy.”
Treatment Comparisons
Pharmacologic options for pediatric headache, although widespread, are limited to off-label treatments. In a 2001 retrospective study, Dr. Kabbouche and colleagues examined the efficacy of prochlorperazine in the emergency department. At one hour, the investigators found that 90% of the 20 studied patients had improved, and 60% of those were headache-free. At three hours, 95% of the patients experienced improvement, and 65% of those went home headache-free. “We have a good improvement rate, but we do not have a very good headache-free rate yet,” Dr. Kabbouche said.
In a 2004 randomized trial comparing prochlorperazine with ketorolac in 62 children and adolescents with migraine, Brousseau et al found an 84.8% response rate for prochlorperazine at one hour, compared with 55.2% for ketorolac. By the end of the study, both treatment groups yielded a 93.3% response rate, but there was also a 30% recurrence rate of some headache symptoms at 24 hours in each group. The study did not provide data regarding possible reasons for the recurrence rate.
In monitoring the emergency department at the Cincinnati Children’s Hospital Medical Center for two months, Dr. Kabbouche said that the rate of patients being admitted to the pediatric emergency department for headache was 3.2%—double the rate of adult admissions. Among these pediatric patients, 33% had chronic headache, 46% had migraine without aura, 8% had migraine with aura, 27% had probable migraine, and 18% had status migrainous.
Prochlorperazine was administered to 36% of pediatric patients admitted to the emergency department for headache. Taken together with other treatments, including IV fluids, ketorolac, or valproic acid, the improvement rate was 63%. The recurrence rate was 29%, and 13% had a persistent headache, evidence that “our treatment didn’t help this group of patients,” Dr. Kabbouche commented. “That shows you the big difference between adults, [of whom] 93% showed improvement of their headache [in the Brousseau study], and kids, who had only 63% improvement.”
However, 6% of the pediatric patients experienced recurrence or a persistent headache. Dr. Kabbouche advised clinicians to consider other treatments, including admission to the hospital for more prolonged therapy, such as dihydroergotamine and valproic acid.
“Our option is not to keep repeating the same treatment in the emergency room,” Dr. Kabbouche said. “There are other options. You can admit them for more aggressive therapy in an inpatient hospital setting.”
—John Merriman