Can prochlorperazine (intravenous) be given to children during an acute migraine attack?

Intravenous Prochlorperazine for Acute Migraine in Children

Intravenous prochlorperazine should not be used in pediatric patients under 20 pounds in weight or under two years of age for acute migraine attacks, but can be effective in older children when administered at the appropriate dosage of 0.15 mg/kg (maximum 10 mg). 1, 2

Evidence for Efficacy in Children

• Prochlorperazine has demonstrated superior efficacy compared to ketorolac in pediatric migraine treatment, with 84.8% of children achieving at least 50% pain reduction within 60 minutes after IV administration 2
• When used in a pediatric emergency department setting, prochlorperazine has shown a treatment success rate of 86% for migraine headaches 3
• The recommended pediatric dosage for IV prochlorperazine is 0.15 mg/kg with a maximum dose of 10 mg 2

Important Considerations and Precautions

• Children appear more prone to developing extrapyramidal reactions even at moderate doses, so using the lowest effective dosage is crucial 1
• Prochlorperazine should not be used in pediatric patients under 20 pounds in weight or under two years of age 1
• Diphenhydramine is often co-administered to prevent akathisia, a common side effect of prochlorperazine 3
• Hypotension is a potential side effect when prochlorperazine is given intravenously, so careful monitoring is required 1, 4
• The FDA label specifically states that prochlorperazine should not be used in conditions for which children's dosages have not been established 1

Alternative First-Line Options for Pediatric Migraine

• Ibuprofen is recommended as first-line medication for acute migraine treatment in children at a dose appropriate for body weight 5
• For adolescents aged 12-17 years, multiple NSAIDs and triptans have been approved for acute migraine treatment 5
• Nasal spray formulations of sumatriptan and zolmitriptan may be more effective in adolescents 5

Treatment Algorithm for Acute Pediatric Migraine

1. For children under 20 pounds or under 2 years: prochlorperazine is contraindicated 1
2. For children over 2 years with adequate weight:
   • First-line: Try ibuprofen at appropriate weight-based dosing 5
   • Second-line: Consider IV prochlorperazine at 0.15 mg/kg (maximum 10 mg) if severe symptoms persist 2
   • Co-administer diphenhydramine to prevent akathisia 3
   • Monitor closely for hypotension and extrapyramidal symptoms 1, 4
3. For adolescents (12-17 years):
   • Consider nasal spray formulations of sumatriptan or zolmitriptan as alternatives 5

Potential Adverse Effects

• The most common adverse effects of IV prochlorperazine in children include hypotension (12%) 4
• Extrapyramidal reactions are more common in children even at moderate doses 1
• Akathisia can be prevented by co-administration of diphenhydramine 3
• Sedation and drowsiness may occur and should be monitored 1

While prochlorperazine can be effective for pediatric migraine in appropriate settings, careful consideration of age, weight, and potential adverse effects is essential before administration.