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Children, Intractable Migraine and IV Prochlorperazine
Am Fam Physician. 2001 Nov 15;64(10):1752.
Migraine headache in children is often treated with ibuprofen. However, treatment of intractable migraine in children is more problematic. Adults with migraine are often treated with prochlorperazine. Kabbouche and colleagues conducted a study to determine if prochlorperazine is an effective and tolerable abortive treatment for severe intractable migraine in children.
Children with headaches were diagnosed by clinical impression and by using the International Headache Society's (IHS) criteria. Children were enrolled consecutively from patients seen in an emergency department after referral to the Headache Center, if home treatment was deemed ineffective. Each child (or the parent) was responsible for determining when the headache was thought to be intractable; no standardized definition was used. The duration and severity of the current headache were recorded, along with information about hydration and abortive medication that had been used to attempt to relieve the headache. A complete history and a physical examination were obtained for each child to exclude alternate diagnoses that might have been related to the prolonged headache.
An intravenous dose of prochlorperazine (approximately 0.15 mg per kg) was given along with intravenous hydration. Subjective response was classified as better, same or worse and response was graded on a 10-point scale. The time to resolution was recorded for each child. Patients (or parents) were contacted 24 hours after discharge and asked about their response at one hour, three hours and 24 hours after administration of the prochlorperazine. Each was also asked about adverse effects of the drug.
The study included 11 girls and nine boys. Diagnosis of migraine (according to IHS criteria) existed in 85 percent of patients; the remaining 15 percent had been clinically diagnosed with migraine but did not meet IHS criteria for migraine. Ibuprofen was used in 12 patients, and a triptan was used in two patients. Nineteen of the 20 children were orally hydrated. All children reported that the headache was their typical migraine, except for the headache's intractability. The mean severity was 8.4 on a 10-point scale. The mean duration of the headache was more than 36 hours if one patient with a 336-hour headache was excluded. Associated symptoms were nausea, vomiting, photophobia and phonophobia.
One hour after the prochlorperazine and intravenous fluid were administered, 90 percent of the patients reported they were feeling better; 10 percent of the patients reported no change in the severity of the headache. In fact, 60 percent of the patients reported complete resolution of headache symptoms one hour after the medication was administered. In those whose headache was not completely relieved, the mean severity decreased from 8.3 to 3.9.
After three hours, 95 percent of patients reported they felt better; one patient was unchanged. Two patients were admitted to the hospital when their headache had not abated after one hour; one of these improved with no further treatment, and one required dihydroergotamine as an abortive treatment. Twenty-four hours after discharge from the emergency department, 90 percent of patients were pain-free; one patient had a recurrence of headache nine hours after discharge and one was continuing treatment with dihydroergotamine. There were no adverse effects reported. More than one half (55 percent) of patients judged the treatment as “good,” and 35 percent judged it as “great.”
The authors conclude that intravenous prochlorperazine combined with intravenous hydration is an ideal treatment in children with intractable migraine headache.
Kabbouche MA, et al. Tolerability and effectiveness of prochlorperazine for intractable migraine in children. Pediatrics. April 4, 2001;107:e62.
Copyright © 2001 by the American Academy of Family Physicians.
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