IV Dihydroergotamine for Treatment of Status Migrainosus in Children - Efficacy and Tolerability (P2.201)

OBJECTIVE: To evaluate the effectiveness and tolerability of intravenous dihydroergotamine (DHE) in children requiring admission for status migrainosus. BACKGROUND: There is limited evidence about status migrainosus management in children, and lack of an established treatment protocol. Prior studies have reported a 70-80[percnt] response to IV DHE, with medication response after about 5 doses. METHODS: This is a retrospective chart review of 36 patients and 40 admissions, ages 7-18 years, who failed other first line medications at home and/or the emergency department, and were admitted to the St. Louis Children’s Hospital from January 2013 to May 2015, for further management with IV DHE. Data were collected on: duration of presenting migraine; medications used prior to admission; effectiveness of DHE treatment based upon pain scores; dose, duration, and frequency of side effects of DHE; and length of admission. RESULTS: Median duration of the presenting headache was 14 days. The emergency department trialed IV NSAIDs with antiemetics in 68[percnt] and IV valproic acid in 40[percnt]. Average length of stay was 4.5 days. Most received a 0.2 mg test dose of DHE, then 0.01 to 0.02 mg/kg/dose every 8 hours if tolerated. Mean number of DHE doses was 3.5. After DHE, there was a statistically significant decrease in pain scores (-2.1 points), 2/3 reported decreased pain, 17[percnt] were headache-free, and 60[percnt] did not require another IV abortive medication. Five percent stopped DHE after the test dose, 65[percnt] experienced side effects, and 25[percnt] stopped DHE due to side effects. CONCLUSIONS: Even if refractory to other IV abortive medications for status migrainosus, DHE can be an effective therapy in children (2/3 respond), but may require several doses. The tolerability of DHE may limit its use, as 2/3 of patients experienced side effects, commonly nausea/emesis despite antiemetic pretreatment, and 1/4 stopped DHE due to side effects.