SOME THOUGHTS ON MIGRAINES FROM FLORIDA… By Sarah Melendez

Greetings everyone from sunny Florida!  As you all know, I’m finishing up my 1^st year of my peds EM fellowship and I just couldn’t stay away from County so I wanted to write a short blog article.  I figured we could talk about something very common in both the pediatric and adult ER……migraines!!!!

Migraines constitute the vast majority of primary headaches in the pediatric and adolescent groups.  Migraine prevalence is around 11% at puberty (so like age 13) but increases over time.  One meta-analysis of over 25,000 cases has shown the incidence to be 2% between the ages of 3-7, 7% between the ages of 7-11 and 20% by the ages of 11-15.  So as you can see, definitely something you will see on your pediatric shifts.

Here’s a quick case.  You have a 16 year old female with a PMH of migraines presenting to the ER for headache x2 days.  She states she normally takes ibuprofen and that will usually terminate her headaches but this time it is more severe and will not stop with her medications at home.  She denies fevers, recent travel or trauma.  On her exam, her VS are normal except for very mild tachycardia, she is photophobic but her pupillary exam is normal and  her fundoscopic exam (YES YOU WERE ABLE TO SEE HER DISCS) was normal.  Her neck is supple without signs of meningismus and the rest of her exam, including neurologic and skin, are normal.  So you diagnose her with migraine and try a couple of medications including toradol, reglan or compazine, Benadryl, Fioricet and all seem to fail.  The patient is still complaining of pain and is asking if there is anything else you can do.  You look up other medications for migraines other than triptans and you come across….PROPOFOL!!!  WHAT?!  Here is some information about this medication as it applies to the pediatric population.

The use of propofol started with the adult migraine population.  There were a total of 2 studies done (one in the 1990s and one more recently in 2012) that looked at adults with intractable migraines.  These patients were given propofol and both studies showed that there was a decrease in the pain scales of the patients involved.  Now since I am talking about pediatrics, I looked up to see if there were any studies done with kids.There was a small retrospective study done in 2012 by Sheridan et al that suggested propofol could be effective in aborting intractable migraines in the ED.  There were 7 children with migraines that were given subanesthetic doses of propofol (average 0.56 mg/kg per bolus, ranging 10-50 mg per bolus, for up to 3 boluses).  These children were then compared to a control group that received the very well known cocktail of NSAIDS, diphenhydramine and prochlorperazine.  Those patients that received the propofol  had a reported reduction in pain scores that was significant (80.1% vs 61.1%).  The study also cited a deceased length of stay among those patients receiving propofol of 122 mins vs 203 mins in the control group but this was deemed not statistically significant.  But what about the side effects?  Well none of the patients experienced adverse side effects such as apnea, hypoventilation or hypoxia.  Now this IS a small study so I would say that larger studies should be done before this becomes standard of care. There is actually more data on the horizon and study NCT01604785 will be recruiting 160 kids to evaluate propofol versus standard treatment for pediatric migraines.

I have tried this method in my ER a grand total of….2 times.  In my experience, this regimen seemed to work and both patients left the ER pain free and happy.  I did look them up to see if they returned to my ED and they did not (although not sure how their pain was at home or if they visited other EDs), so in my opinion it was worth trying.

Obviously you should check with your attending and with your hospital policies regarding the use of propofol but here are a few tips and recommendations on how to use this medication if you are interested.

• Consider for patients failing usual rescue treatments
• Follow your ED’s protocol for procedural sedation
• Administer subanesthetic doses of propofol at 0.3-0.5 mg/kg per dose (max dose of 50mg) every 10 mins for up to 1mg/kg total.
• Aim to have a lightly sedated patient, even less sedated than your moderate sedation cases.

I would love to hear if anyone else has used propofol for this indication and if so, what was your experience?

References:

1)      Sheridan DC, et al. Low-dose propofol for the abortive treatment of pediatric migraine in the emergency department. Pediatric Emerg Care. 2012;28(12):1293-1296.

2)      Krusz JC, et al. Intravenous propofol: unique effectiveness in treating intractable migraines. Headache. 2000;40(3)224-230.

3)      Split W, et al. Epidemiology of migraine among students from randomly selected secondary schools in Lodz. Headache. 1999;39(7):494-501.

4)      Sillanpaa, M. Prevalence of headache in prepuberty. Headache 1983;23(1):10-14.

5)      Pakalnis A, et al. headaches and hormones. Semin Pediatric Neurology. 2010;17(2):100-104.

6)      Coralac, Z. ALiEMOn the Horizon: Propofol for Migraines.

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