PEDIATRICS

Abstract

Study objective: We compare the effectiveness of intravenous ketorolac and intravenous prochlorperazine in the treatment of pediatric migraine headaches. Methods: We performed a prospective, randomized, double‐blind clinical trial in two pediatric emergency departments (EDs) within children's hospitals. Children aged 5 to 18 years presenting to the ED with migraine headaches were eligible for the study. Contraindications to either medication or the inability to complete the pain score resulted in exclusion. Children were randomized to receive intravenous ketorolac (.5 mg per kilogram; maximum 30 mg) or intravenous prochlorperazine (.15 mg per kilogram; maximum 10 mg). All children also received a normal saline solution bolus. Successful treatment was defined as a 50% or greater reduction in the Nine Faces Pain Scale score at 60 minutes. If a less than 50% improvement occurred by 60 minutes, the child received the other medication. Forty‐eight‐hour follow‐up telephone calls were made to each family to assess recurrence and late side effects. Results: Sixty‐two children were enrolled: 33 initially received prochlorperazine, and 29 initially received ketorolac. By 60 minutes, 16 (55.2%) of 29 children who received ketorolac and 28 (84.8%) of 33 children who received prochlorperazine were successfully treated (difference = 30%; 95% confidence interval [CI] 8% to 52%). Fifty‐six (93.3%) of the 60 children who completed the study were successfully treated by the study's conclusion. Approximately 30% of each group had a recurrence of some headache symptoms. Only two children reported side effects, both mild and self‐limited. Conclusion: In children, intravenous prochlorperazine is superior to intravenous ketorolac in the acute treatment of migraine headaches. Comments: Neuroleptics do work in terminating migraine (Wang SJ, Silberstein SD, Young WB. Droperidol treatment of status migrainosus and refractory migraine. Headache. 1997; 37:377‐382), and this may be related to a dopaminergic accelerator hypothesized by Dr. Stephen Peroutka (Peroutka SJ. Dopamine and migraine. Neurology. 1997;49:650‐656). Stewart J. Tepper We would have difficulty using intravenous prochloperazine (UK trademark STEMETIL) in the United Kingdom since the parental formulation is licensed only for intramuscular use in both adults and children. Furthermore, our national formulary recommends only oral dosing of prochlorperazine children, due to a high frequency of extrapyramidal effects {http://www.bnf.org/bnf/index.html}. I assume both ketorolac and prochlorperazine are licensed for i.v. use in North America, but are there any more pediatric data? David S. Millson