New guidelines for emergency dept management of acute migraine in children

Migraine affects 10% of children and adolescents. It occurs in females more often than males and has a mean onset at 12 years of age. Migraine accounts for 30% of pediatric headache visits to the emergency department and frequent repeat visits. Evidence is limited on managing migraine attacks in children in the emergency department and significant differences in management approach have been seen among treatment centres. To reduce the variation in treatment among healthcare providers and prevent potential harm to patients, the Canadian Paediatric Society (CPS) has issued a practice point on the management of acute migraine in children and adolescents presenting to the emergency department. The document focuses on pharmacologic management of moderate to severe migraine in children and adolescents who have been unresponsive to home therapy (acetaminophen, ibuprofen and/or a triptan).The CPS practice point summarizes evidence for the treatment of pain in acute migraine, including the use of dopamine antagonists (metoclopramide), intravenous (IV) ketorolac, ibuprofen, acetaminophen, triptans, intranasal lidocaine, IV valproic acid (only available through Health Canada’s Special Access Program), IV magnesium, greater occipital nerve blocks and opioids. It also discusses the use of ondansetron for treatment of nausea and vomiting in acute migraine. Corticosteroids and nutraceuticals (riboflavin, coenzyme Q10, magnesium) are also discussed briefly as preventive options.Best practice pointsBased on the evidence outlined in the practice point, the CPS provides several best practice points:Initial management of acute migraine might include ibuprofen, a triptan (if presenting within 2 hours of attack onset) and an oral antiemetic (ondansetron) depending on the initial patient presentation.IV fluids should be administered based on hydration status.IV metoclopramide is the recommended approach for children with acute migraine presenting to the emergency department.Based on limited evidence in children, IV ketorolac may not provide added benefit to metoclopramide monotherapy.Greater occipital nerve blocks and intranasal lidocaine are potential second-line treatment options for children. Their use should be based on the healthcare provider’s clinical expertise and patient preference.IV valproic acid, IV magnesium sulfate and opioids are not recommended therapies for acute migraine in children.Data are inadequate on the use of dexamethasone to prevent recurrence of migraine, but riboflavin, coenzymeQ10 and oral magnesium can be offered for prophylaxis in children with frequent attacks.Treatment algorithmThe practice point includes an algorithm for treating pediatric acute migraine in the emergency department. The initial assessment could include giving ibuprofen 10 mg/kg (maximum 600 mg) if no nonsteroidal anti-inflammatory drug (NSAID) has been taken within the last four hours, a triptan if less than two hours have passed from the onset of migraine, ondansetron orally disintegrating tablet 0.15 mg/kg (maximum 8 mg) if the child is experiencing nausea and vomiting, and an IV fluid bolus if the child is dehydrated. Specific migraine treatment would then include IV metoclopramide 0.15 mg/kg (maximum 10 mg/dose, infused over 15–30 minutes) with or without IV ketorolac 0.5 mg/kg (maximum 30 mg/dose, IV push over 1–5 minutes) if no NSAID has been taken within four hours.Consideration could be given to greater occipital nerve block (lidocaine 2%, 1–2 mL injected over the right and left greater occipital nerves) or intranasal lidocaine 2% solution, 0.5 mL/nostril using a nasal mucosal atomizer device (total 1 mL/dose). The child could be discharged home, with consideration given to prescribing riboflavin (vitamin B2) 50–400 mg once daily, coenzyme Q10 (1–3 mg/kg/day once daily) or magnesium (9 mg/kg/day elemental magnesium divided into 3 daily doses) for migraine prevention, if the child has a high frequency of migraine attacks. All three have some low-quality supportive evidence for use in migraine prevention in children and adolescents. Alternatively, if there is no improvement after acute migraine treatment, the child could be admitted to hospital or transferred to an alternate care facility.Pediatric drug doses The CPS practice point includes a table summarizing pediatric doses of drugs used for acute migraine and for migraine prophylaxis, as well as their potential adverse effects. Summary Overall, the CPS concludes that pediatric-specific evidence on acute migraine treatment is sparse. Therefore, treatments are often based on adult data. Pediatric high-quality evidence is needed to improve treatment for children presenting with migraine.Reference:Rogers S, Orr SL, Parisien B, et al; Canadian Paediatric Society, Acute Care Committee. Pharmacological management of acute migraine attacks in children and adolescents presenting to the emergency department. (accessed December 29, 2025).

New guidelines for emergency dept management of acute migraine in children

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