Children With Migraines Get Inadequate Care at Adult EDs

MONTREAL — Children with acute migraine are less likely to be treated according to practice guidelines or with a medication of proven efficacy for pediatric populations, or to have been effectively treated at all if they are cared for in an adult rather than pediatric emergency department, according to a presentation by Dr. Lawrence Richer at the 10th International Child Neurology Congress.

“Adult and pediatric ERs within the same city differ in their treatment of headaches and migraines in children,” commented Dr. Richer, a pediatric neurologist at the University of Alberta, Edmonton, who said this choice “remains the single most important factor in determining outcome.”

Investigators conducted a chart review of 382 children treated for headache or migraine between July 2003 and July 2004 in four emergency departments (three adult, one pediatric) in Edmonton. Of these children, 65% were seen in the pediatric emergency department. The children ranged in age from 2 to 17 years, with a mean age of 11.4 years. About 12% had a previous head injury, and about 11% had symptoms of recent infection.

Richer found management differed between adult and pediatric emergency departments. Children with acute migraines were more likely to have blood work, a lumbar puncture, or a computed tomography scan or other neuroimaging procedure if they were treated at an adult ED than if they went to the pediatric ED.

Children in adult EDs were less likely to be given more than one treatment and more likely to be discharged while symptoms remained unresolved.

NSAIDs—most often acetaminophen—were the most popular first-line therapies in both EDs. Opiates such as codeine and morphine were used less often, although when given they were administered more frequently for children seen in adult EDs than pediatric EDs. Dopamine antagonists were more often prescribed in pediatric than adult EDs. Oral or intravenous triptans were not used in the emergency setting.

Do these treatment choices reflect practice guidelines? In December 2004 (midway through the patient acquisition phase of Dr. Richer's study), the American Academy of Neurology released guidelines for treating patients with pediatric migraine, and these guidelines were endorsed by the American Academy of Pediatrics and the American Headache Society (Neurology 2004;63:2215–24).

Although no agents are currently approved by the Food and Drug Administration for the acute treatment of migraine in children or adolescents, the guidelines indicated evidence that ibuprofen was effective and acetaminophen was probably effective. No mention was made of the use of opioids. While the guidelines indicated that no adequate data supported or refuted the use of any oral or subcutaneous triptan preparation, good data were available favoring the use of sumatriptan nasal spray for adolescents—a medication apparently not offered by the emergency departments surveyed.

MONTREAL — Children with acute migraine are less likely to be treated according to practice guidelines or with a medication of proven efficacy for pediatric populations, or to have been effectively treated at all if they are cared for in an adult rather than pediatric emergency department, according to a presentation by Dr. Lawrence Richer at the 10th International Child Neurology Congress.

“Adult and pediatric ERs within the same city differ in their treatment of headaches and migraines in children,” commented Dr. Richer, a pediatric neurologist at the University of Alberta, Edmonton, who said this choice “remains the single most important factor in determining outcome.”

Investigators conducted a chart review of 382 children treated for headache or migraine between July 2003 and July 2004 in four emergency departments (three adult, one pediatric) in Edmonton. Of these children, 65% were seen in the pediatric emergency department. The children ranged in age from 2 to 17 years, with a mean age of 11.4 years. About 12% had a previous head injury, and about 11% had symptoms of recent infection.

Richer found management differed between adult and pediatric emergency departments. Children with acute migraines were more likely to have blood work, a lumbar puncture, or a computed tomography scan or other neuroimaging procedure if they were treated at an adult ED than if they went to the pediatric ED.

Children in adult EDs were less likely to be given more than one treatment and more likely to be discharged while symptoms remained unresolved.

NSAIDs—most often acetaminophen—were the most popular first-line therapies in both EDs. Opiates such as codeine and morphine were used less often, although when given they were administered more frequently for children seen in adult EDs than pediatric EDs. Dopamine antagonists were more often prescribed in pediatric than adult EDs. Oral or intravenous triptans were not used in the emergency setting.

Do these treatment choices reflect practice guidelines? In December 2004 (midway through the patient acquisition phase of Dr. Richer's study), the American Academy of Neurology released guidelines for treating patients with pediatric migraine, and these guidelines were endorsed by the American Academy of Pediatrics and the American Headache Society (Neurology 2004;63:2215–24).

Although no agents are currently approved by the Food and Drug Administration for the acute treatment of migraine in children or adolescents, the guidelines indicated evidence that ibuprofen was effective and acetaminophen was probably effective. No mention was made of the use of opioids. While the guidelines indicated that no adequate data supported or refuted the use of any oral or subcutaneous triptan preparation, good data were available favoring the use of sumatriptan nasal spray for adolescents—a medication apparently not offered by the emergency departments surveyed.

MONTREAL — Children with acute migraine are less likely to be treated according to practice guidelines or with a medication of proven efficacy for pediatric populations, or to have been effectively treated at all if they are cared for in an adult rather than pediatric emergency department, according to a presentation by Dr. Lawrence Richer at the 10th International Child Neurology Congress.

“Adult and pediatric ERs within the same city differ in their treatment of headaches and migraines in children,” commented Dr. Richer, a pediatric neurologist at the University of Alberta, Edmonton, who said this choice “remains the single most important factor in determining outcome.”

Investigators conducted a chart review of 382 children treated for headache or migraine between July 2003 and July 2004 in four emergency departments (three adult, one pediatric) in Edmonton. Of these children, 65% were seen in the pediatric emergency department. The children ranged in age from 2 to 17 years, with a mean age of 11.4 years. About 12% had a previous head injury, and about 11% had symptoms of recent infection.

Richer found management differed between adult and pediatric emergency departments. Children with acute migraines were more likely to have blood work, a lumbar puncture, or a computed tomography scan or other neuroimaging procedure if they were treated at an adult ED than if they went to the pediatric ED.

Children in adult EDs were less likely to be given more than one treatment and more likely to be discharged while symptoms remained unresolved.

NSAIDs—most often acetaminophen—were the most popular first-line therapies in both EDs. Opiates such as codeine and morphine were used less often, although when given they were administered more frequently for children seen in adult EDs than pediatric EDs. Dopamine antagonists were more often prescribed in pediatric than adult EDs. Oral or intravenous triptans were not used in the emergency setting.

Do these treatment choices reflect practice guidelines? In December 2004 (midway through the patient acquisition phase of Dr. Richer's study), the American Academy of Neurology released guidelines for treating patients with pediatric migraine, and these guidelines were endorsed by the American Academy of Pediatrics and the American Headache Society (Neurology 2004;63:2215–24).

Although no agents are currently approved by the Food and Drug Administration for the acute treatment of migraine in children or adolescents, the guidelines indicated evidence that ibuprofen was effective and acetaminophen was probably effective. No mention was made of the use of opioids. While the guidelines indicated that no adequate data supported or refuted the use of any oral or subcutaneous triptan preparation, good data were available favoring the use of sumatriptan nasal spray for adolescents—a medication apparently not offered by the emergency departments surveyed.