Pediatric Inpatient Headache Therapy: What Is Available
Pediatric Inpatient Headache Therapy: What Is Available
Status migrainosus is defined by the international classification of headache disorders (ICHD) criteria as a debilitating migraine lasting more then 72 hours. The epidemiology of status migrainosus is still unknown in adult and children, and frequently underdiagnosed.
Children and adolescents often end up in the emergency room with an intractable headache that failed outpatient therapy. Six to seven percent of these children do not respond to acute infusion therapy and require hospitalization.
It is imperative that more aggressive therapy is considered when patients are affected by a severe intractable headache to prevent further disability and returning the child to baseline activity.
Multiple therapies are available for adults and children. Studies for acute therapy in the emergency room are available in adults and pediatric groups. Small studies are available for inpatient therapy in children and, along with available therapies for children and adolescents, are described in this review. A review of the literature shows growing evidence regarding the use of dihydroergotamine intravenously once patients are hospitalized. Effectiveness and safety have been proven in the last decades in adults and small studies in the pediatric populations.
Migraine is a chronic disorder defined by exacerbations that usually subside with a well-targeted outpatient headache therapy. It has been reported that 5.3% of adolescents have experienced a migraine headache by the age of 15.
When a headache lasts more than 72 hours, the diagnosis of status migrainosus is applied. Status migrainosus is considered a complication of migraine according to the new ICHD-III beta criteria (1.4.1), defined as a debilitating migraine attack with emphasis on the severity, disability and the need of aggressive therapy for quick relief.
Children and adolescents in status migrainosus are usually referred to the emergency room or infusion centers. The referral is necessary at this point to control the episode and prevent further disability.
Headache persists for approximately 6–7% of the patients treated in the emergency room or infusion center, thus requiring hospitalization. The prevalence of status migrainous is not known. Comprehensive epidemiological studies have yet to be conducted so far in either pediatric or adult populations.
This debilitating headache can occur in a child with intermittent migraine or as an exacerbation on top of a chronic headache. Akhtar and Rothner performed a retrospective review of status migrainosus over 8 years and were able to only clearly define 14 patients with status migrainosus: 8/14 had an occurrence in the setting of intermittent migraine and 3/14 had the exacerbation on top of a chronic migraine. Regardless, the exacerbation should be treated promptly. The prevalence of status migrainosus is likely much higher than was described by Akhtar and Rothner. Their study was probably limited by a lack of detailed information in the charts reviewed.
Treatment, however, often poses a challenge in the pediatric population due to the lack of controlled studies as well as the presence of discomfort by general pediatricians and neurologists in using available, effective, therapies in pediatric populations.
Multiple therapeutic approaches are presently available including most prominently: intravenous hydration, parenteral dopamine antagonists, sodium valproate, dihydroergotamine (DHE), magnesium sulfate, and steroids. These regimens are not food and drug administration (FDA) approved for the treatment of acute exacerbations of headache in children and adolescents but efficacy as well as tolerability has been reviewed in small pediatric studies. This article will review, briefly, a few select approaches that have shown efficacy and tolerability for debilitating attacks in pediatric populations.
Abstract and Introduction
Abstract
Status migrainosus is defined by the international classification of headache disorders (ICHD) criteria as a debilitating migraine lasting more then 72 hours. The epidemiology of status migrainosus is still unknown in adult and children, and frequently underdiagnosed.
Children and adolescents often end up in the emergency room with an intractable headache that failed outpatient therapy. Six to seven percent of these children do not respond to acute infusion therapy and require hospitalization.
It is imperative that more aggressive therapy is considered when patients are affected by a severe intractable headache to prevent further disability and returning the child to baseline activity.
Multiple therapies are available for adults and children. Studies for acute therapy in the emergency room are available in adults and pediatric groups. Small studies are available for inpatient therapy in children and, along with available therapies for children and adolescents, are described in this review. A review of the literature shows growing evidence regarding the use of dihydroergotamine intravenously once patients are hospitalized. Effectiveness and safety have been proven in the last decades in adults and small studies in the pediatric populations.
Introduction
Migraine is a chronic disorder defined by exacerbations that usually subside with a well-targeted outpatient headache therapy. It has been reported that 5.3% of adolescents have experienced a migraine headache by the age of 15.
When a headache lasts more than 72 hours, the diagnosis of status migrainosus is applied. Status migrainosus is considered a complication of migraine according to the new ICHD-III beta criteria (1.4.1), defined as a debilitating migraine attack with emphasis on the severity, disability and the need of aggressive therapy for quick relief.
Children and adolescents in status migrainosus are usually referred to the emergency room or infusion centers. The referral is necessary at this point to control the episode and prevent further disability.
Headache persists for approximately 6–7% of the patients treated in the emergency room or infusion center, thus requiring hospitalization. The prevalence of status migrainous is not known. Comprehensive epidemiological studies have yet to be conducted so far in either pediatric or adult populations.
This debilitating headache can occur in a child with intermittent migraine or as an exacerbation on top of a chronic headache. Akhtar and Rothner performed a retrospective review of status migrainosus over 8 years and were able to only clearly define 14 patients with status migrainosus: 8/14 had an occurrence in the setting of intermittent migraine and 3/14 had the exacerbation on top of a chronic migraine. Regardless, the exacerbation should be treated promptly. The prevalence of status migrainosus is likely much higher than was described by Akhtar and Rothner. Their study was probably limited by a lack of detailed information in the charts reviewed.
Treatment, however, often poses a challenge in the pediatric population due to the lack of controlled studies as well as the presence of discomfort by general pediatricians and neurologists in using available, effective, therapies in pediatric populations.
Multiple therapeutic approaches are presently available including most prominently: intravenous hydration, parenteral dopamine antagonists, sodium valproate, dihydroergotamine (DHE), magnesium sulfate, and steroids. These regimens are not food and drug administration (FDA) approved for the treatment of acute exacerbations of headache in children and adolescents but efficacy as well as tolerability has been reviewed in small pediatric studies. This article will review, briefly, a few select approaches that have shown efficacy and tolerability for debilitating attacks in pediatric populations.