title: The Use of a Pediatric Migraine Practice Guideline in an Emergency Department Setting.
abstract: OBJECTIVE
  The aim of the study was to evaluate the safety and efficacy of a standardized pediatric migraine practice guideline in the emergency department (ED).
  
  
  METHODS
  Migraine Clinical Practice Guideline (MCPG) was created in collaboration with the Division of Pediatric Neurology and Pediatric Emergency Medicine. The MCPG was established on evidence-based data and best practice after a review of the literature. The MCPG was implemented for patients with a known diagnosis of migraine headaches and a verbal numeric pain score (VPS) greater than 6 on a 0 to 10 scale. Patients received intravenous saline, ketorolac, diphenhydramine, and either metoclopramide or prochlorperazine. After 40 minutes, another VPS was obtained, and if no improvement, a repeat dose of metoclopramide or prochlorperazine was administered. If after 40 minutes and minimal pain relief occurred, a consult to neurology was made. A chart review of patients enrolled in the MCPG from April 2004 to April 2013 was conducted. We recorded demographic data, vital signs, ED length of stay, initial VPS, last recorded VPS, adverse events, and admission rate. Nonparametric statistics were performed.
  
  
  RESULTS
  A total of 533 charts were identified with a discharge diagnosis of migraine headache of which 266 were enrolled in the MCPG (179 females and 87 males). Mean (SD) age was 13.9 (3.1). Mean (SD) initial VPS was 7.8 (2.0). Mean (SD) discharge VPS was 2.1 (2.8), representing a 73% reduction of pain. Twenty patients (7.5%) were admitted for status migrainosus; mean (SD) age was 14.0 (3.5) years and mean (SD) VPS was 6.3 (2.8). Mean (SD) length of stay in ED was 283 (107) minutes. No adverse events were identified.
  
  
  CONCLUSIONS
  Our MCPG was clinically safe and effective in treating children with acute migraine headaches. Our data add to the dearth of existing published literature on migraine treatment protocols in the ED setting. We recommend additional prospective and comparative studies to further evaluate the effectiveness of our protocol in this patient population.
authors.affiliation: From the Department of Pediatrics, Division of Emergency Medicine, Saint Louis University School of Medicine, Saint Louis, MO.
authors.forename: Courtney R J
authors.initials: CR
authors.lastname: Kaar
authors.forename: James M
authors.initials: JM
authors.lastname: Gerard
authors.forename: Albert K
authors.initials: AK
authors.lastname: Nakanishi
mesh_terms: D000293:Adolescent; D000894:Anti-Inflammatory Agents, Non-Steroidal / Q000627:therapeutic use; D000932:Antiemetics / Q000627:therapeutic use; D004087:Dihydroergotamine / Q000627:therapeutic use; D004155:Diphenhydramine / Q000627:therapeutic use; D004636:Emergency Service, Hospital / Q000592:standards*; D005260:Female; D019983:Guideline Adherence; D006801:Humans; D006993:Hypnotics and Sedatives / Q000627:therapeutic use; D020910:Ketorolac / Q000627:therapeutic use; D007902:Length of Stay / Q000706:statistics & numerical data; D008297:Male; D008787:Metoclopramide / Q000627:therapeutic use; D008881:Migraine Disorders / Q000188:drug therapy*; D059408:Pain Management; D010147:Pain Measurement; D017410:Practice Guidelines as Topic; D011346:Prochlorperazine / Q000627:therapeutic use; D016896:Treatment Outcome; D014662:Vasoconstrictor Agents / Q000627:therapeutic use
chemical_list: D000894:Anti-Inflammatory Agents, Non-Steroidal; D000932:Antiemetics; D006993:Hypnotics and Sedatives; D014662:Vasoconstrictor Agents; D004087:Dihydroergotamine; D004155:Diphenhydramine; D008787:Metoclopramide; D011346:Prochlorperazine; D020910:Ketorolac