A comparison of acute treatment regimens for migraine in the emergency department
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Published on: January 18, 2018
Richard G Bachur1, Michael C Monuteaux2, Mark I Neuman2
1Division of Emergency Medicine, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts richard.bachur@childrens.harvard.edu.
Insights
Prochlorperazine is more effective than metoclopramide for preventing pediatric migraine emergency department revisits. Diphenhydramine use increases revisit risk in children treated for migraine.
Area of Science:
- Pediatric Emergency Medicine
- Pharmacology
- Health Services Research
Background:
- Migraine is a frequent reason for pediatric emergency department visits.
- Limited research exists on acute therapies for pediatric migraines in emergency settings.
- Effective acute treatments are needed to prevent emergency department (ED) revisits.
Purpose of the Study:
- To compare the effectiveness of acute medication regimens for pediatric migraine.
- To identify treatments that reduce the likelihood of emergency department revisits within 3 days.
- To inform clinical practice regarding optimal abortive migraine therapy in pediatric EDs.
Main Methods:
- Retrospective analysis of administrative data from 35 pediatric EDs (2009-2012).
- Included children aged 7-18 years with a primary migraine diagnosis.
- Primary outcome was ED revisit within 3 days; compared treatment regimens and individual medications.
Main Results:
- Of 32,124 children with migraine, 5.5% of discharged patients revisited the ED within 3 days.
- Metoclopramide was associated with a 31% increased odds of revisit compared to prochlorperazine.
- Diphenhydramine combined with dopamine antagonists increased revisit odds by 27% versus dopamine antagonists alone.
Conclusions:
- Most children with migraine are successfully treated and discharged from the ED.
- Prochlorperazine demonstrated superior efficacy in preventing revisits compared to metoclopramide.
- Diphenhydramine use in acute migraine treatment is linked to higher return rates to the ED.
Background And Objectives:
Migraine headache is a common pediatric complaint among emergency department (ED) patients. There are limited trials on abortive therapies in the ED. The objective of this study was to apply a comparative effectiveness approach to investigate acute medication regimens for the prevention of ED revisits.
Methods:
Retrospective study using administrative data (Pediatric Health Information System) from 35 pediatric EDs (2009-2012). Children aged 7 to 18 years with a principal diagnosis of migraine headache were studied. The primary outcome was a revisit to the ED within 3 days for discharged patients. The primary analysis compared the treatment regimens and individual medications on the risk for revisit.
Results:
The study identified 32,124 children with migraine; 27,317 (85%) were discharged, and 5.5% had a return ED visit within 3 days. At the index visit, the most common medications included nonopioid analgesics (66%), dopamine antagonists (50%), diphenhydramine (33%), and ondansetron (21%). Triptans and opiate medications were administered infrequently (3% each). Children receiving metoclopramide had a 31% increased odds for an ED revisit within 3 days compared with prochlorperazine. Diphenhydramine with dopamine antagonists was associated with 27% increased odds of an ED revisit compared with dopamine antagonists alone. Children receiving ondansetron had similar revisit rates to those receiving dopamine antagonists.
Conclusions:
The majority of children with migraines are successfully discharged from the ED and only 1 in 18 required a revisit within 3 days. Prochlorperazine appears to be superior to metoclopramide in preventing a revisit, and diphenhydramine use is associated with increased rates of return.
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