Pediatric Headache in Emergency Medicine Medication
- Author: Kirsten A Bechtel, MD; Chief Editor: Richard G Bachur, MD more...
Medication Summary
If the diagnosis is not a surgical condition that requires immediate operative treatment, the emphasis of medical therapy should be to provide analgesia and to treat the underlying cause of headache. In patients with migraine, tension, and posttraumatic headache, the goals of therapy are to relieve pain, alleviate nausea, and promote sleep. Vasoconstrictive agents may also be helpful, especially if the onset of the migraine headache is recent.
Analgesics
Class Summary
These agents are indicated for the treatment of mild to moderate pain and headache. They are the mainstays of headache treatment.
Aspirin (Bayer Aspirin, Empirin)
Treats mild to moderate pain. Inhibits prostaglandin synthesis, which prevents formation of platelet-aggregating thromboxane A2.
Acetaminophen (Tylenol, Tempra)
DOC for pain in patients with documented hypersensitivity to aspirin or NSAIDs, upper GI disease, or current oral anticoagulant use.
Ibuprofen (Advil, Motrin)
NSAID that is DOC for patients with mild to moderate pain. Inhibits inflammatory reactions and pain by decreasing prostaglandin synthesis.
Morphine
DOC for analgesia because of reliable and predictable effects, safety profile, and ease of reversibility with naloxone. Most potent of the opiate agonists and is useful for the acute management of headache due to migraine.
Various IV doses are used and are commonly titrated until desired effect obtained. Its use is cautioned in conditions with raised intracranial pressure.
Sedative
Class Summary
This agent promotes sleep in children with migraine headache.
Chloral hydrate (Aquachloral)
CNS depressant. Mechanism of action unknown.
Vasoconstrictors
Class Summary
Although the pathophysiology is uncertain, abnormalities of the cerebral vasculature, causing vasoconstriction, and then vasodilation, is the most often cited mechanism for migraine. A reduction in regional cerebral blood flow during the aura and early headache phases of migraine has been demonstrated. This is the rationale behind the use of vasoconstrictive agents in the treatment of migraine. Therapeutic activity of the serotonin 5-HT1 receptor agonists (ie, triptans) in migraine is most likely attributed to agonist effects at 5-HT 1B/1D receptors. These specific receptor subtypes act on the extracerebral, intracranial blood vessels that become dilated during a migraine attack and on nerve terminals in the trigeminal system. Triptans have not been FDA approved for children younger than 18 years.
The American Academy of Neurology quality standards subcommittee and the practice committee of the Child Neurology Society have provided guidelines for treating migraine headaches in children and adolescents.[9]
Ergotamine (Ergomar)
Alpha-adrenergic and serotonin (5HT1) antagonist and partial agonist (depending on receptor site). Causes constriction of peripheral and cranial blood vessels. Useful in classic and common migraine headache. Works best if used in early stages of migraine. Significant nausea and vomiting has been associated with its use.
Sumatriptan (Imitrex)
Selective agonist for serotonin 5-HT1 receptors (probably 5HT1D) in cranial arteries and suppresses inflammation associated with migraine headaches. Useful in common and classic migraine during early stages of headache.
As of now, has had no formal approval for use in headache relief for children. However, accumulating evidence from several clinical studies indicates efficacy and safety in that population, and many child neurologists are beginning to use triptans in children. The decision to choose these drugs might be best reserved for consultation.
Zolmitriptan (Zomig, Zomig-ZMT)
For symptomatic relief. Selective serotonin (5HT1) receptor agonist in cranial arteries; elicits vasoconstriction and reduce inflammation associated with antidromic neuronal transmission in CH. High affinity for 5-HT 1D and 5-HT 1B receptor subtypes.
Can reduce severity of headache within 15 min of SC injection. As of now, has had no formal approval for use in headache relief for children. However, accumulating evidence from several clinical studies indicates efficacy and safety in that population, and many child neurologists are beginning to use them in children. The decision to choose these drugs might be best reserved for consultation.
Naratriptan (Amerge, Naramig)
Selective 5-HT1 agonist with a long half-life. High affinity for 5-HT 1D receptor subtype. Duration of action up to 24 h with low headache recurrence rate. Useful for patients with slow-onset prolonged migraine, such as menstrual migraine.
As of now, has had no formal approval for use in headache relief for children. However, accumulating evidence from several clinical studies indicates efficacy and safety in that population, and many child neurologists are beginning to use them in children. The decision to choose these drugs might be best reserved for consultation.
Rizatriptan (Maxalt, Maxalt-MLT)
Selective agonist for serotonin 5-HT1 receptors in cranial arteries and suppresses the inflammation associated with migraine headaches. High affinity for 5-HT 1D and 5-HT 1B receptor subtypes.
As of now, has had no formal approval for use in headache relief for children. However, accumulating evidence from several clinical studies indicates efficacy and safety in that population, and many child neurologists are beginning to use them in children. The decision to choose these drugs might be best reserved for consultation.
Almotriptan (Axert)
Used to treat acute migraine. Selective 5-HT1B/1D/1F receptor agonist. Results in cranial vessel constriction, inhibition of neuropeptide release, and reduced pain transmission in trigeminal pathways.
As of now, has had no formal approval for use in headache relief for children. However, accumulating evidence from several clinical studies indicates efficacy and safety in that population, and many child neurologists are beginning to use them in children. The decision to choose these drugs might be best reserved for consultation.
Frovatriptan (Frova)
Selective 5-HT1 agonist with long half-life. High affinity for 5-HT 1D and 5-HT 1B receptor subtypes. Has duration of action as long as 24 h with low headache recurrence rate. Useful for patients with slow-onset, prolonged migraine, such as menstrual migraine. Has long half-life (ie, 26-30 h), thus decreases recurrence of migraine within 24 h after treatment.
As of now, has had no formal approval for use in headache relief for children. However, accumulating evidence from several clinical studies indicates efficacy and safety in that population, and many child neurologists are beginning to use them in children. The decision to choose these drugs might be best reserved for consultation.
Eletriptan (Relpax)
Selective serotonin agonist. Specifically acts at 5-HT1B/1D/1F receptors on intracranial blood vessels and sensory nerve endings to relieve pain associated with acute migraine.
As of now, has had no formal approval for use in headache relief for children. However, accumulating evidence from several clinical studies indicates efficacy and safety in that population, and many child neurologists are beginning to use them in children. The decision to choose these drugs might be best reserved for consultation.
Antiemetics
Class Summary
These agents are useful in the treatment of symptomatic nausea.
Promethazine (Phenergan)
Blocks postsynaptic mesolimbic dopaminergic receptors in brain and reduces stimuli to brainstem reticular system. Antiemetic and antihistaminic actions that alleviate nausea and vomiting and promote sleep.
Metoclopramide (Reglan)
Metoclopramide promotes gastric emptying and has antiemetic effects, which are useful to treat the nausea and vomiting associated with migraine.
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