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In the pediatric patient diagnosed with refractory migraine is sumatriptan an effective treatment for refractory migraine in the ED?


Plain language summary from the office of evidence based practice: Based on very low quality evidence, the Migraine in the ED CPG team makes a conditional recommendation that sumatriptan may be considered to treat a patient who presents with a refractory migraine.

Literature synthesis: The AAN Practice Parameter (Lewis et al., 2004) states sumatriptan is effective for acute migraine. However, (Hamalainen, Hoppu, & Santavuori, 1997) reported no difference in pain at 2 hours between children treated with sumatriptan (PO) or placebo (N= 46) OR = 0.09, 95% CI [0.17, 0.34]. (Winner, Rothner, Wooten, Webster, & Ames, 2006) compared sumatriptan nasal spray at two doses to placebo. They report pain relief at two hours was significantly better at 2 hours with 20mG of sumatriptan (nasal spray).There is reporting and attrition bias in this report. Although they report ITT analysis, per protocol analysis was used in the report, and the denominator of included subjects varies. (McDonald et al., 2011) reported the results of a long term cohort study on use of sumatriptan (PO) on migraine. Ninety-one percent (7791/8517) migraines were treated with sumatriptan/naproxen alone and rescue medications were not needed. Forty-two percent of the migraines were pain free within two hours of administration, and rescue medications were not required. This study is indirect evidence to the question, as treatment was started at home, at first sign of a migraine, not in the ED. It is recommended that sumatriptan be taken when migraine symptoms are first noticed (Scholpp, Schellenberg, Moeckesch, & Banik, 2004). Patients who present to the ED for the management of their migraine pain have usually had a migraine for a longer time.

Dihydroergotamine should not be administered if sumatriptan has been taken within the past 24 hours. (Lexicomp Online, 2013)

See Appendix I for the full Critically Appraised Topic (CAT).

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.