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Emergency Department Pediatric Headache/Migraine Management Algorithm

Emergency Department Pediatric Headache/Migraine Management Algorithm - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Clinical Practice Guidelines, Neurology, Related


Child presents with
headache
Red flag
symptoms?
Off guideline, evaluate for
secondary causes, treat as
clinically indicated
Child likely has
migraine?
Initiate non-pharmacologic strategies
(place in dark room, quiet area)
Assess for contraindications, pregnancy, allergies
Can Child
tolerate PO?
Rehydrate/IV fluids as needed
(IV fluids likely needed if severe pain)
Consider triptan or
triptan/naproxen
(if not already taken)
Consider ondansetron for nausea
IV fluids
AND
Consider Ketorolac
AND/OR
Dopamine Receptor
Antagonist (+/-)
diphenhydramine
Assess for nephrotoxicity risk
w/Ketorolac if oral NSAID
taken already
Migraine
Relief?
Consult neurology
Consider triptan or
IV DHE or
IV corticosteroids or
IV Magnesium or
IV Valproic acid
Plan for possible admission for
Mg infusion
Migraine
Relief?
Admission, and treat
as indicated
Abortive Migraine Medications 
Medication  Dose  Route  Max 
Ibuprofen 10 mg/kg PO 800 mg
Ondansetron 0.1 mg/kg PO, IV 4 mg
Ketorolac 0.5 mg/kg IV 30 mg
Diphenhydramine 1-2 mg/kg IV 50 mg
Metoclopramide 0.1-0.5
mg/kg
IV 10 mg
Prochlorperazine 0.1-0.15
mg/kg
IV 10 mg
Valproic Acid 15-20
mg/kg
IV 1000 mg
Magnesium 25-50
mg/kg
IV 2000 mg
*Opiates are NOT recommended for migraine
*Consider pregnancy test for adolescent females
before giving ketorolac, dopamine receptor
antagonists, DHE or valproic acid
NO
Discharge
Discharge
Emergency Department Pediatric Headache/Migraine Management Algorithm
YES
Discharging Patient:
*Reinforce lifestyle habits to improve/reduce
pain and prevent migraine recurrence
- adequate sleep
- diet (avoid trigger foods, caffeine)
- stay well hydrated
- exercise
- recognizing triggers, maintaining headache
diary
*Discharge with follow-up to PCPC or Peds
Neurology
*Prior to discharge, patient should have options
to treat headache at home. If no options or if
considering oral bridge of ED treatment, consider
discharge with medication(s) (e.g. if no previous
triptan prescription, oral prochloperazine or oral
methylprednisolone)
*Counsel patient to limit medication overuse to
prevent rebound headache (use abortive meds 2-
3 times per week max)
NO
Red flag symptoms:
* Systemic symptoms of fever, weight loss, chills
* Neurologic deficits, altered consciousness
* Sudden onset, abrupt or split second
*First headache or different from previous
headache history is different/change to
headache
Consider imaging headache with signs of:
-increased intracranial pressure
-positive neurological signs
-presence of systemic symptoms
including but not limited to fever and
nuchal rigidity
Migraine without aura criteria:
* ≥ 5 headaches, each lasting 4-72 h if untreated
* Any 2 of following:
-unilateral
-pulsatile
-moderate to severe intensity
- worse with extension
And at least one of following:
-nausea and/or vomiting
-photo and phonophobia
YES
Home management
attempted?
YES
NO
YES
YES
NO
YES
NO
NO
Migraine
relief?
NO
YES
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
03/2017CCKM@uwhealth.org