ER Treatment for Migraine-Associated Vomiting in a 7-Year-Old
For a 7-year-old child presenting to the ER with migraine-associated vomiting, administer ibuprofen 7.5-10 mg/kg as the first-line analgesic combined with ondansetron 0.15 mg/kg IV (maximum 4 mg) for the vomiting, using non-oral routes given the active emesis. 1, 2
First-Line Treatment Approach
Ibuprofen at 7.5-10 mg/kg is the recommended first-line medication for pediatric migraine and should be given as early as possible, though the oral route may not be feasible with active vomiting 1
Ondansetron 0.15 mg/kg IV (maximum 4 mg) is specifically indicated for children unable to take oral medications due to persistent vomiting, including migraine-associated vomiting 2
The combination addresses both the headache pain and the disabling nausea/vomiting component, which is particularly prominent in pediatric migraine compared to adults 1
When Oral Route Fails
Intranasal sumatriptan (5-20 mg) is the most effective non-oral option for children who cannot tolerate oral medications due to vomiting 1
This bypasses the gastrointestinal tract entirely and provides migraine-specific treatment when NSAIDs cannot be administered orally 3, 1
Consider this as a second-line option if IV ondansetron does not adequately control vomiting to allow oral ibuprofen administration 1
Role of IV Fluids
IV fluid hydration alone provides minimal clinically significant benefit for pediatric migraine, with only 17.8% of children achieving meaningful pain reduction with IV fluids alone 4
While many ED protocols include IV fluid boluses, the evidence shows the overall decrease in pain is small and clinically insignificant 4
IV fluids may still be appropriate for children with clinical dehydration from prolonged vomiting, but should not be relied upon as primary migraine treatment 4
Critical Pitfalls to Avoid
Limit acute medication use to no more than twice weekly to prevent medication-overuse headache, which can develop even in children 1
Avoid opioids, which have poor efficacy and risk of dependency and are not recommended for pediatric migraine 5
Do not delay treatment - migraine medications are most effective when administered early in the attack 1, 5
If the child requires ER treatment more than 2 days per week, preventive therapy should be initiated rather than increasing acute medication frequency 1
Additional Considerations
Metoclopramide 0.1-0.2 mg/kg IV (maximum 10 mg) is an alternative antiemetic that provides both antiemetic effects and direct migraine analgesia through dopamine receptor antagonism, though ondansetron has a more favorable side effect profile in children 3, 2
Prochlorperazine 0.15 mg/kg IV is another option but has higher rates of dystonic reactions in pediatric patients 3
Ensure regular meals, adequate hydration, and consistent sleep schedules as part of discharge planning 1
Headache recurrence is common (33% within 24 hours after ED discharge), so provide clear return precautions and follow-up instructions 4
When to Escalate Care
If acute medication provides insufficient relief after adequate trials of both ibuprofen and intranasal sumatriptan, referral to pediatric neurology or headache specialist is indicated 1
Consider preventive therapy consultation if attacks occur more than 2 days per month and continue to impair quality of life despite optimized acute treatment 1