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Migraine Therapy in the ED

Guideline inclusion criteria: 

  • Children up to 18 years of age

  • Physical exam normal

  • History consistent with primary headache

Guideline exclusion criteria:

  • Abnormal physical exam normal

  • History inconsistent with primary headache


Migraine headaches are a common complaint in children. The frequency of migraine occurrence increases through adolescent. The prevalence of migraines increases with age:

  • children age 3 - 7 years of age the migraine prevalence is 3%

  • children 4 - 11 years of age it is reported to be 4 - 11%

  • children 11 - 15 years of age the prevalence is reported to be 8 - 23% (Lewis, et al., 2004).

The mean age onset of migraines is 7.2 years for males and 10.9 for females (Lewis, et al.).

The patient with a refractory headache will typically present with:

  • Headache attack lasting 1 to 72 hours

  • Headache has at least 2 of the following 4 features:

    • Either bilateral or unilateral (frontal/temporal) location

    • Pulsating quality

    • Moderate to severe intensity

    • Aggravated by routine physical activities

  • At least 1 of the following accompanies headache:

    • Nausea and/or vomiting

    • Photophobia and phonophobia (may be inferred from their behavior) (Lewis et al., 2004).

Differential diagnosis:

  • Tension headache

  • Cluster headache

These guidelines do not establish a standard of care to be followed in every case. It is recognized that each case is different and those individuals involved in providing health care are expected to use their judgment in determining what is in the best interests of the patient based on the circumstances existing at the time. It is impossible to anticipate all possible situations that may exist and to prepare guidelines for each. Accordingly these guidelines should guide care with the understanding that departures from them may be required at times.