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Published on: June 2, 2014
Emergency department management of acute migraine in children in Canada: a practice variation study
Lawrence Richer1, Lee Graham, Terry Klassen
1University of Alberta-Pediatrics, Division of Neurology, Edmonton, Alberta, Canada.
Insights
Treatment for pediatric migraine in emergency departments (EDs) varies significantly. Pediatric EDs are more likely to use dopamine antagonists, while mixed EDs more often prescribe opiates, highlighting a need for more clinical trials.
Area of Science:
- Pediatric Emergency Medicine
- Neurology
- Clinical Practice Guidelines
Background:
- Limited evidence-based guidelines exist for treating pediatric migraine, particularly in emergency departments (EDs).
- Randomized controlled trials (RCTs) are scarce, leading to practice variations.
Purpose of the Study:
- To characterize current treatments for children with migraine in the ED.
- To determine if treatment strategies differ between pediatric-only and mixed adult/pediatric EDs.
Main Methods:
- Retrospective chart review of children (5-17 years) diagnosed with headache or migraine in 4 Edmonton EDs (2003-2004).
- Migraine classification based on the International Classification of Headache Disorders II.
- Analysis of treatment variations between pediatric and mixed EDs.
Main Results:
- Of 382 cases, 48.7% met migraine criteria. No treatment was administered in 44.2%.
- First-line treatments included simple oral analgesics (23.3%) and dopamine antagonists (20.7%). Opiates and ketorolac were used infrequently.
- Pediatric EDs more frequently prescribed dopamine antagonists (12.9% vs. 6.8%), while mixed EDs more often prescribed opiates (28.1% vs. 18.4%).
- Polypharmacy (31.2%) and neuroimaging (29.1%) were common. Outcomes were poorly documented.
Conclusions:
- Significant practice variations exist in managing pediatric migraine between pediatric and mixed EDs.
- Most children do not receive drug therapy; specific drug choices differ by ED type.
- Further clinical trials are needed to establish evidence-based guidelines for pediatric migraine treatment.
Objectives:
Evidence-based guidelines for the treatment of children with migraine are limited given the paucity of randomized controlled trials, especially in the emergency department (ED). Our objectives were to: (1) characterize the treatment of children with migraine in the ED; (2) determine whether treatment varies in pediatric versus mixed (pediatric and adult) EDs.
Methods:
Children aged 5 to 17 years presenting to 4 regional emergency departments in Edmonton, Alberta, Canada during the 2003/2004 fiscal year with a diagnostic code of headache or migraine were selected. A standardized retrospective chart abstraction was performed and migraine or probable migraine cases were classified based on the International Classification of Headache Disorders II.
Results:
Three hundred and eighty-two cases were identified of which 48.7% (n = 186/382) met sufficient criteria for migraine. No treatment was given in 44.2% (n = 169/382). Simple oral analgesics (23.3%; n = 89/182) and dopamine antagonists (metoclopramide and prochlorperazine; 20.7%; n = 79/182) were prescribed first-line most commonly. Opiate medications (5.5%), ketorolac (4.7%), dihydroergotamine (1%) were prescribed first-line infrequently. There was a significant difference in the management choices between pediatric and mixed adult/pediatric EDs (chi(2)= 19.695; df = 5; P= .001). The pediatric ED was more likely to prescribe a dopamine antagonist (12.9 vs 6.8%; P= .044) while the mixed adult/pediatric EDs were more likely to prescribe an opiate (28.1% vs 18.4%; P= .031). Children with migraine in all EDs were significantly more likely to receive drug therapy (68.3% vs 42.9%; P < .001) or a dopamine antagonist (32.3% vs 9.7%; P < .001). Polypharmacy (31.2%; n = 119/382) and neuroimaging (29.1%; n = 111/382) were common. Outcome was poorly documented overall. No adverse events were recorded.
Conclusions:
Significant variation in practice in the management of acute headaches in children was observed between mixed population and pediatric-only emergency physicians in the same city. Most children do not receive any drug therapy. Children presenting to the pediatric ED were significantly more likely to receive a dopamine antagonist while opiates were prescribed more commonly in the mixed ED. More clinical trials are required in children to clarify areas of clinical uncertainty on which evidence-based practice guidelines can be formed.
