Background: Migraine headache is a common disorder in pediatrics. Children experiencing migraine headache that cannot be managed with oral medications may require hospital admission for treatment. Inpatient treatment typically involves a poly-pharmaceutical approach, including dihydroergotamine (DHE) for intractable migraine headaches. At our institution, patients receive DHE if other medications fail to abort migraine headache.. DHE is started at a lower dose (0.1 – 0.25mg) and increased in increments every 8 hours to a maximum of 1 mg. When DHE does not result in the improvement of pain scores after the final dose of DHE, patients receive a nerve block. While one study in adults(1) showed that 5-day treatment protocol produced a better outcome, the effectiveness of DHE for migraine headache treatment has not been systematically studied in pediatric patients.The objective of our study was to assess the efficacy of DHE on headache alleviation in children with migraine headache.
Methods: Retrospective chart review was conducted on patients between age 6 to 18 years discharged from 2010 to 2018 with a primary diagnosis of migraine headache. Patients with an infectious process, complex care needs, or incomplete data (lack of pain scores or DHE dosage) were excluded. Response to DHE was measured by patient self-reported pain scores after administration of up to 10 doses of DHE per patient. Descriptive statistical tools as well as Pearson’s correlation tests were used to compare the data groups. This study was approved by local IRB.
Results: 1239 patients with a discharge diagnosis of Migraine headache were identified. These patients were predominantly female (76.9%), non-Hispanic ethnicity (76.7 %) and white race (90.9%) with a mean age of 14.1 years. Of these, 573 patients met inclusion criteria. Table 1 shows that the mean pain scores decreased from 6.05 (before the first dose) to 4.05 (after first and before last dose) to 2.04 (after last dose). 25% of the patients (n=140 out of 561 patients, 12 patients had incomplete data about DHE and nerve blocks) did not have improvement in pain scores with following the final dose of DHE. The correlation coefficient between average pain score before and after first dose of DHE was 0.556 (Figure 1A; p < 0.0001). The correlation coefficient between average pain scores between the first and last dose and after the last dose was 0.634 (Figure 1B; p< 0.0001).
Conclusions: Our results indicate that comparable to adults, 75% of pediatric patients exhibit pain relief from migraine headache following administration of DHE. Significant pain relief occurred following a single dose of DHE. Subsequent dosing optimized this effect; however, it is unclear whether this was related to cumulative dose effect or increasing dose size. Additional studies, including randomised controlled trials, are needed to identify the most effective dose and treatment regimen for the use of DHE in pediatric patients with migraine headaches.
