A 14 year old male presents with gradual onset headache with blurry vision, photophobia, and right forearm “tingling.” He has had similar headaches previously, and this does not represent his worst headache. No neck stiffness.

Comprehensive neuro exam is normal, visual acuity is 20/20 with no field deficits. No objective findings on physical exam.

You make the presumptive diagnosis of migraine headache. What evidence-based treatment should you initiate?

  1. Ibuprofen. Multiple studies show safety and efficacy over both acetaminophen and placebo. Acetaminophen is also shown to be more effective than placebo, but less effective than ibuprofen at 2 hours post-treatment.
  2. Sumitriptangiven either via nasal spray (IN) or subcutaneously (SQ). Nasal administration has been studied extensively and is effective over placebo; PO triptans have not shown to be useful in the acute setting for children. The jury is still out on SQ, but it may be considered when IN is unavailable.
  3. Prochlorperazine IV was shown in a single study to be effective as a second-line agent when compared to ketorolac.
The 2004 AAP-endorsed AAN recommendations for migraine in children are as follows:
  • Ibuprofen: Safe, effective, should be considered
  • Acetaminophen: Probably effective, should be considered
  • Sumatriptan nasal spray: Effective, should be considered
  • Oral triptans: No data to support or refute use
  • SQ triptans: Inadequate data to judge efficacy

 

Sources:

  • Walker DM, Teach SJ. Emergency department treatment of primary headaches in children and adolescents. Curr Opin Pediatr. 2008 Jun;20(3):248-54.
  • Bailey B, McManus BC. Treatment of children with migraine in the emergency department: a qualitative systematic review. Pediatr Emerg Care. 2008 May;24(5):321-30.