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Migraine
  • Intranasal sumatriptan
  • PO ibuprofen
  • Oral rehydration
  • Headache care: dim lights, decrease stimulation

  • IV hydration (2nd NS bolus)
  • IV Magnesium sulfate

  • Consult Neurology
  • Consider DHE (see DHE pathway)
  • Consider Valproic acid

Inclusion Criteria
  • Persistent headache
Exclusion Criteria
  • Age < 5
  • Abnormal neurologic exam
  • Signs of ICP
  • Fever
  • Seizure
  • Closed head injury within 24 hours
  • VP shunt
  • IV hydration (20 ml/kg NS bolus)
  • Metoclopramide IV or Prochlorperazine IV
  • Diphenhydramine IV

  • Intranasal sumatriptan
  • IV hydration (20 ml/kg NS bolus)
  • Metoclopramide IV
  • Diphenhydramine IV or Prochlorperazine IV
  • Ketorolac IV
  • Headache care: dim lights, decrease stimulation

Discharge, headache education

Consider: stroke, hemorrhage, intracranial mass, meningitis, trauma/concussion, vasculitis, pseudotumor cerebri, shunt malfunction

Discharge, headache education

Dosing:

  • PO Ibuprofen: 10 mg/kg (max 800 mg/dose)
  • IV Ketorolac: 0.5 mg/kg (max 30 mg/dose)
  • IV/PO Diphenhydramine: 0.5-1 mg/kg (max 50 mg/dose)
  • IV/PO Metoclopramide: 0.2 mg/kg (max < 12 yo: 10 mg/dose; max > 12 yo: 20 mg/dose)
  • IV/PO Prochlorperazine 0.1 mg/kg (max 10 mg/dose)
  • IV Magnesium: 30 mg/kg (max 2000 mg/dose)

  • Migraine is a clinical diagnosis
  • Routine imaging is NOT recommended
  • Thorough H&P will identify patients who need further diagnostic testing/imaging

References:

1) John Muir Medical Center DHE protocol (internal document).

2) Seattle Children's Migraine Clinical Pathway v1.0. http://seattlechildrens.org/pdf/migraine-pathway.pdf.

3) Children's Hospital of Philadelphia Clinical Pathways Migraine Headache, Emergent Care. http://www.chop.edu/clinical-pathway/migraine-headache-emergent-care-clinical-pathway.

4) Children's Hospital of Philadelphia Clinical Pathways Migraine Headache, Inpatient Care. http://www.chop.edu/clinical-pathway/migraine-headache-inpatient-treatment-clinical-pathway.




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