Inpatient Clinical Pathway for the Evaluation/Treatment
of Children with a Migraine Headache
- Consider Differential Diagnosis
- History & Physical, Admit Note (.ipneuro)
- Labs, Imaging
- Additional Testing - New/Worsening Headache
- Review ED, Pre-hospital Care, Prior Medications, Failed Treatments
- If No Prior Medications, Administer Medications Per ED Migraine Pathway
- Medication Dosing & Comments
- Timing
- Response
- Current Pain Score
- Testing Related to Treatment for All Patients
- Sufficient Clinical Improvement
- Decreases in Pain Score by 1 Point
- Patient Reports Subjective Improvement
- Reassess Every 8-12 Hours to Ensure Continued Improvement
- Consider Adjunctive Pain Management Interventions
- Patient Education
- Child Life
- Social Work
- Psychology/Psychiatry
- Integrative Health
Pathway assumes patient has received Ketorolac, Metoclopramide, and Valproic Acid at this point.
If additional medications administered in ED, advance along pathway as clinically indicated.
Modify protocol as needed dependent on success/failure/side effects of past medications.
Sufficient Improvement
Start | Diphenhydramine |
Continue | Ketorolac Metoclopramide Valproic Acid |
- Medications
- Suggested Progression of Medications
- Dosing, Duration Other Comments
- Assessing Pain
- DHE Protocol/Progression/Side Effect Management
Insufficient Improvement
Stop | Valproic Acid |
Start | Diphenhydramine Methylprednisolone |
Continue | Ketorolac Metoclopramide |
Reassess 30-60 Minutes Following Methylprednisolone
Sufficient Improvement
Insufficient Improvement
Stop | Ketorolac |
Start | Famotidine |
Continue | Metoclopramide Diphenhydramine Methylprednisone |
Stop | Methylprednisolone |
Start | Magnesium Sulfate |
Continue | Ketorolac Metoclopramide Diphenhydramine |
Reassess 30-60 Minutes after Magnesium Sulfate
Sufficient Improvement
Insufficient Improvement
Continue | Magnesium Sulfate Ketorolac Metoclopramide Diphenhydramine |
Stop | Magnesium Sulfate |
Start | DHE |
Continue | Ketorolac Metoclopramide Diphenhydramine |
Sufficient Improvement
Continue | DHE Ketorolac Metoclopramide Diphenhydramine |
- DHE Protocol/Progression/
Side Effect Management - If insufficient improvement after 3 Doses
- Discuss Nerve Block
- Consider Valproic Acid, Magnesium
- If insufficient improvement after 5 doses
- Consider Levetiracetam
Evidence
- A Comparison of Acute Treatment Regimens for Migraine in the Emergency Department
- Effectiveness of Standardized Combination Therapy for Migraine Treatment in the Pediatric Emergency Department
- Treatment of Pediatric Migraine Headaches: a Randomized, Double-blind Trial of Prochlorperazine Versus Ketorolac.
- Approach to Pediatric Intractable Migraine
- Headaches in Children and Adolescents
- Treatment of pediatric migraine in the emergency room.
CHOP Programs
Educational Media
- RN Learning Module
- Primary Care Perspectives: Podcast for Pediatricians
Episode 141: Managing Pediatric Migraine Headaches in Primary Care