Richer Lawrence, Graham Lee, Klassen Terry, Rowe Brian
University of Alberta-Pediatrics, Division of Neurology, Edmonton, Alberta, Canada.
Headache. 2007 May;47(5):703-10. doi: 10.1111/j.1526-4610.2007.00782.x.
Evidence-based guidelines for the treatment of children with migraine are limited given the paucity of randomized controlled trials, especially in the emergency department (ED). Our objectives were to: (1) characterize the treatment of children with migraine in the ED; (2) determine whether treatment varies in pediatric versus mixed (pediatric and adult) EDs.
Children aged 5 to 17 years presenting to 4 regional emergency departments in Edmonton, Alberta, Canada during the 2003/2004 fiscal year with a diagnostic code of headache or migraine were selected. A standardized retrospective chart abstraction was performed and migraine or probable migraine cases were classified based on the International Classification of Headache Disorders II.
Three hundred and eighty-two cases were identified of which 48.7% (n = 186/382) met sufficient criteria for migraine. No treatment was given in 44.2% (n = 169/382). Simple oral analgesics (23.3%; n = 89/182) and dopamine antagonists (metoclopramide and prochlorperazine; 20.7%; n = 79/182) were prescribed first-line most commonly. Opiate medications (5.5%), ketorolac (4.7%), dihydroergotamine (1%) were prescribed first-line infrequently. There was a significant difference in the management choices between pediatric and mixed adult/pediatric EDs (chi(2)= 19.695; df = 5; P= .001). The pediatric ED was more likely to prescribe a dopamine antagonist (12.9 vs 6.8%; P= .044) while the mixed adult/pediatric EDs were more likely to prescribe an opiate (28.1% vs 18.4%; P= .031). Children with migraine in all EDs were significantly more likely to receive drug therapy (68.3% vs 42.9%; P < .001) or a dopamine antagonist (32.3% vs 9.7%; P < .001). Polypharmacy (31.2%; n = 119/382) and neuroimaging (29.1%; n = 111/382) were common. Outcome was poorly documented overall. No adverse events were recorded.
Significant variation in practice in the management of acute headaches in children was observed between mixed population and pediatric-only emergency physicians in the same city. Most children do not receive any drug therapy. Children presenting to the pediatric ED were significantly more likely to receive a dopamine antagonist while opiates were prescribed more commonly in the mixed ED. More clinical trials are required in children to clarify areas of clinical uncertainty on which evidence-based practice guidelines can be formed.
鉴于随机对照试验匮乏，尤其是在急诊科（ED），针对儿童偏头痛治疗的循证指南有限。我们的目标是：（1）描述急诊科中儿童偏头痛的治疗情况；（2）确定儿科急诊科与混合（儿科和成人）急诊科的治疗是否存在差异。
选取2003/2004财政年度在加拿大艾伯塔省埃德蒙顿市4个地区急诊科就诊、诊断代码为头痛或偏头痛的5至17岁儿童。进行标准化回顾性病历摘要，并根据《国际头痛疾病分类II》对偏头痛或可能的偏头痛病例进行分类。
共识别出382例病例，其中48.7%（n = 186/382）符合偏头痛的充分标准。44.2%（n = 169/382）未接受任何治疗。最常作为一线用药的是简单口服镇痛药（23.3%；n = 89/182）和多巴胺拮抗剂（甲氧氯普胺和丙氯拉嗪；20.7%；n = 79/182）。阿片类药物（5.5%）、酮咯酸（4.7%）、双氢麦角胺（1%）作为一线用药的情况较少。儿科急诊科与混合成人/儿科急诊科的管理选择存在显著差异（χ² = 19.695；自由度 = 5；P = .001）。儿科急诊科更有可能开具多巴胺拮抗剂（12.9%对6.8%；P = .044），而混合成人/儿科急诊科更有可能开具阿片类药物（28.1%对18.4%；P = .031）。所有急诊科中偏头痛患儿接受药物治疗（68.3%对42.9%；P < .001）或多巴胺拮抗剂（32.3%对9.7%；P < .001）的可能性显著更高。联合用药（31.2%；n = 119/382）和神经影像学检查（29.1%；n = 111/382）很常见。总体而言，结局记录不佳。未记录到不良事件。
在同一城市，混合人群急诊科医生与仅诊治儿科患者的急诊科医生在儿童急性头痛管理方面的实践存在显著差异。大多数儿童未接受任何药物治疗。到儿科急诊科就诊的儿童更有可能接受多巴胺拮抗剂治疗，而在混合急诊科中阿片类药物的开具更为常见。需要针对儿童开展更多临床试验，以明确临床不确定性领域，从而形成循证实践指南。
