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.