AUSTIN—Standard combination therapy (SCT)—a nonsteroidal anti-inflammatory drug and antidopaminergic agent, with or without diphenhydramine—is used in 39% of children with migraine in a tertiary care pediatric emergency department, according to research presented at the 2013 Annual Meeting of the Child Neurology Society.
Lalitha Sivaswamy, MD, and colleagues retrospectively reviewed 2,208 patients who were diagnosed with headache and presented to the emergency department at the Wayne State University School of Medicine in Detroit between June 2011 and June 2012. The most common diagnosis was headache not otherwise specified (headache-NOS). A total of 158 patients fulfilled the criteria for migraine with or without aura, per the International Classification of Headache Disorders, 2nd edition. Patients who had comorbidities that might contribute to headache were excluded.
The investigators analyzed adherence to SCT among participants regarding ethnicity, gender, age, and severity of headache and evaluated the effect of SCT on the duration of emergency department stay and the need for hospital admission. The researchers used Fisher’s exact test and the Mann–Whitney test to compare data between the group who had received SCT and the group who had not received SCT. Logistic regression analysis was used to determine which factors were associated with hospitalization.
The mean age of the SCT group was 14, compared with 13 for the non-SCT group. Seventy-one percent of the SCT group were female, compared with 69% of the non-SCT group; 38% of the SCT group were Caucasian, and 29% of the non-SCT group were Caucasian. In addition, 79% of the SCT group had a severe headache, compared with 72% of the non-SCT group.
The researchers found that 61 of the 158 patients (39%) had received SCT. “Adherence to SCT did not vary by age, gender, ethnicity, duration of headache prior to emergency department visit, or the severity of headache,” stated Dr. Sivaswamy, Medical Director of the Headache Clinic, Children’s Hospital of Michigan, in Detroit.
The investigators reported that 37 patients required admission to the hospital. “Admission rates were higher in children who received SCT (31.1% vs 18.6%), though not statistically significant,” reported the researchers.
The use of SCT, presence of nausea, and use of opiates were the factors most likely to increase the odds for hospital admission. The average stay in the emergency department for patients who were discharged home was 4.1 hours in the SCT group, compared with 3.2 hours in the non-SCT group.
“SCT was not widely utilized in a tertiary care pediatric emergency department setting,” stated the researchers. “Use of SCT did not positively influence duration of emergency department stay or the hospital admission rates. Larger studies across pediatric emergency departments nationwide are required before SCT can be accepted as the best practice parameter.”
The proposal to use standard combination therapy as the standard of care for children with migraine who present to the emergency department was made by Leung et al in 2013. In this study, SCT reduced pain scores, hospital admission rates, and the duration of emergency department stay in children with migraine. No standard of care or practice parameters have been established by the Child Neurology Society or the American Academy of Pediatrics regarding this condition, according to Dr. Sivaswamy.
“There appears to be significant variation in clinical practice as far as treatment of pediatric migraine in the emergency setting is concerned, and this has been well studied in Canada,” Dr. Sivaswamy told Neurology Reviews. “Similar studies are lacking in the United States. Therefore, larger studies examining this issue at a national level may shed light on practice variations across the country.”
—Colby Stong