1. In acute migraine, prochlorperazine administration was associated with fewer emergency department (ED) return visits when compared to treatment with other dopamine antagonists.
2. The use of diphenhydramine was associated with an increased likelihood of return to the ED.
Evidence Rating Level: 2 (Good)
Study Rundown: Migraine headaches are a common presenting complaint in pediatric EDs. However, there have been very few pediatric trials comparing abortive therapies for migraine in the ED. This study retrospectively examined the treatment of migraine in children, comparing various therapies including non-opioid analgesics, dopamine antagonists, and ondansetron.
The use of non-opioid analgesics alone was associated with the lowest rate of return to ED, likely due to the lower severity of headache. Furthermore, when compared to other dopamine antagonists, prochlorperazine was associated with a lower likelihood of ED revisit. There was no significant difference in the odds of revisit when comparing ondansetron to dopamine antagonists. In addition, the use of diphenhydramine with a dopamine antagonist was associated with slightly increased odds of ED revisit. One limitation is the lack of differentiation between prophylactic diphenhydramine and the treatment of actual extrapyramidal side effects from dopamine antagonists. In addition, the study could not discern migraine severity nor the primary diagnosis for ED revisits, making it difficult to interpret the true efficacy of therapy. Nonetheless, these findings provide guidance for future investigation into abortive migraine therapies and suggest that prochlorperazine may be the most effective dopamine antagonist in acute migraine.
In-Depth [retrospective cohort study]: This study retrospectively examined 32 124 children from 2009 to 2012 between the ages of 7 and 18 who had a primary diagnosis of migraine in the ED. Data was taken from the Pediatric Health Information System, a database of free-standing children’s hospitals. The majority of subjects (66.9%) were female and the median age at presentation was 14 years. Most patients (85%) were discharged directly from the ED and 5.5% of those had a return visit with 3 days. The use of non-opioid analgesics alone had the lowest rate of ED revisit at 4.4%. The use of prochlorperazine was associated with a lower odds of revisit when compared to metoclopramide (aOR = 1.31, CI 1.11-1.55). There was no significant difference in the odds of revisit between ondansetron and dopamine antagonists (aOR = 0.90, CI 0.77-1.07). In contrast, the use of diphenhydramine in addition to any dopamine antagonist was associated with an increased odds of revisit (aOR = 1.27, CI 1.07-1.51). Of note, only 3% of children received a triptan despite their known efficacy as abortive therapy in adults.
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