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Abstract
Headache and seizures are two of the most common complaints seen in the field of pediatric neurology with headache being number one. Both these conditions may coexist. Where the difficulty begins is when the symptoms are not clear cut in making a diagnosis, and conditions are possible as either an atypical seizure or migraine variant. What further complicates matters is the fact that there are many underlying neurologic conditions that carry with them a higher likelihood of developing both headaches and seizures, making each a distinct possibility when obtaining a history from a parent about unusual spells. Although differentiating between seizure and headache may not be easy, with a focused yet thorough history and appropriate use of investigative tools, it can be done. Coming to the correct diagnosis is only the start; once seizures and or headaches have been appropriately diagnosed then the real challenge begins and that is finding a way to successfully treat the headaches and seizures. Within pediatric neurology, the acute options tend to be more diagnosis specific whereas the prophylactic ones may overlap and treat both headaches and seizures. In the following review, we will discuss the epidemiology of pediatric headaches and seizures, the overlap between these 2 conditions in diagnosis, as well as how to tell them apart, and the treatment options and prognosis of both common neurologic disorders in children.
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Affiliation(s)
- Christopher B Oakley
- Departments of Neurology and Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD.
| | - Eric H Kossoff
- Departments of Neurology and Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD
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Kabbouche M, Khoury CK. Management of Primary Headache in the Emergency Department and Inpatient Headache Unit. Semin Pediatr Neurol 2016; 23:40-3. [PMID: 27017021 DOI: 10.1016/j.spen.2015.08.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Migraine is a chronic disorder with debilitating exacerbations throughout the lifetime of migraineurs. Children and adolescents are significantly affected. The prevalence of migraine in this age group is higher than predicted in the last decade. Fortunately, this chronic disease is getting more attention and recognition, and better treatments are now being offered to these patients. Different medications are available, mostly for the outpatient management of an attack and include the use of over-the-counter anti-inflammatory medications as well as prescribed medications like the triptans group. These therapies do sometime fail and the exacerbations can last days to weeks. Early aggressive intravenous treatment can be very effective in breaking the attack and allowing the child to be functional faster and sometimes may prevent chronification of an attack.
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Affiliation(s)
- Marielle Kabbouche
- Division of Neurology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH; University of Cincinnati College of Medicine, Cincinnati, OH.
| | - Chaouki K Khoury
- Texas A&M Health Sciences Center, Round Rock, TX; Baylor University Medical Center and Our Children's House at Baylor, Dallas, TX
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Kacperski J, Kabbouche MA, O’Brien HL, Weberding JL. The optimal management of headaches in children and adolescents. Ther Adv Neurol Disord 2016; 9:53-68. [PMID: 26788131 PMCID: PMC4710107 DOI: 10.1177/1756285615616586] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
The recognition of the diagnosis of migraine in children is increasing. Early and aggressive treatment of migraine in this population with the use of over-the-counter medications has proven effective. The off-label use of many migraine-specific medications is often accepted in the absence of sufficient evidenced-based trials. Mild to severe cases of migraine should be treated with nonsteroidal anti-inflammatory drugs, with triptans used in moderate to severe headaches unresponsive to over-the-counter therapy. Rescue medication including dihydroergotamine [DHE] should be used for status migrainosus, preferably in the hospital setting. Antiemetics that have antidopaminergic properties can be helpful in patients with associated symptoms of nausea and vomiting through their action on central migraine generation. Furthermore, patients and families should be educated on nonpharmacologic management such as lifestyle modification and avoidance of triggers that can prevent episodic migraine.
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Affiliation(s)
- Joanne Kacperski
- Division of Neurology, Cincinnati Children’s Hospital Medical Center, University of Cincinnati College of Medicine, 3333 Burnett Avenue, Cincinnati, OH 45229, USA
| | - Marielle A. Kabbouche
- Division of Neurology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA and University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Hope L. O’Brien
- Division of Neurology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA and University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Jessica L. Weberding
- Division of Neurology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
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Kabbouche M. Management of Pediatric Migraine Headache in the Emergency Room and Infusion Center. Headache 2015; 55:1365-70. [PMID: 26486800 DOI: 10.1111/head.12694] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2015] [Revised: 08/11/2015] [Accepted: 08/11/2015] [Indexed: 11/30/2022]
Abstract
Migraine is a common disorder that starts at an early age and takes a variable pattern from intermittent to chronic headache with several exacerbations throughout a lifetime. Children and adolescents are significantly affected. If an acute headache is not aborted by outpatient migraine therapy, it often causes severe disability, preventing the child from attending school and social events. Treating the acute severe headache aggressively helps prevent prolonged disability as well as possible chronification. Multiple medications are available, mostly for the outpatient management of an attack and include the use of over-the-counter anti-inflammatory medications as well as prescribed medications in the triptan group. These therapies do sometime fail and the exacerbation can last from days to weeks. If the headache lasts 72 hours or longer it will fall in the category of status migrainosus. Status migrainosus is described as a severe disabling headache lasting 72 hours or more by the ICHD3 criteria. Disability is a major issue in children and adolescents and aggressive acute measures are to be taken to control it as soon as possible. Early aggressive intravenous therapy can be very effective in breaking the attack and allowing the child to be quickly back to normal functioning. This article reviews what is available for the treatment of pediatric primary headaches in the emergency room.
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Affiliation(s)
- Marielle Kabbouche
- Division of Neurology, University of Cincinnati College of Medicine, Cincinnati, OH, 45229-3039, USA (M. Kabbouche).,Division of Neurology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, 45229-3039, USA (M. Kabbouche)
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Gungor F, Akyol KC, Kesapli M, Celik A, Karaca A, Bozdemir MN, Eken C. Intravenous dexketoprofen vs placebo for migraine attack in the emergency department: A randomized, placebo-controlled trial. Cephalalgia 2015; 36:179-84. [PMID: 25944813 DOI: 10.1177/0333102415584604] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2014] [Accepted: 04/07/2015] [Indexed: 11/17/2022]
Abstract
OBJECTIVE Migraine is a leading headache etiology that frequently presents to the emergency department (ED). In the present study, we aimed to determine the efficacy of dexketoprofen in aborting migraine headaches in the ED. METHODS This prospective, randomized, double-blind study was conducted in an ED of a tertiary care hospital using allocation concealment. Patients were allocated into two arms to receive the study drug; 50 mg dexketoprofen in 50 ml saline and 50 ml saline as placebo. Change in pain intensity was measured by the visual analog scale at baseline, both at 30 and 45 minutes after the study medication was administered. Rescue medication requirement and pain relapse were also recorded by a telephone follow-up at 48 hours. RESULTS A total of 224 patients (112 in each group) were included into the final analysis. Mean age of the study participants was 37 ± 11 (SD) and 25% (n = 56) of them were male. The median pain improvement at 45 minutes for patients receiving dexketoprofen was 55 (IQR: 49 to 60) and 30 (IQR: 25 to 35) for those receiving placebo. The mean difference between the two groups at 45 minutes was 21.4 (95% CI: 14.4. to 28.5). Rescue drugs were needed in 22.3% of patients who received dexketoprofen compared to 55.4% in patients who received placebo (dif: 33.1%; 95% CI: 20% to 45%). There were no adverse events reported in either group during the study period. CONCLUSION Intravenous dexketoprofen is superior to placebo in relieving migraine headaches in the ED. It may be a suitable therapy with minimum side effects in patients presenting with a migraine headache to the ED.
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Affiliation(s)
- Faruk Gungor
- Antalya Training and Research Hospital, Department of Emergency Medicine, Turkey
| | - Kamil Can Akyol
- Antalya Training and Research Hospital, Department of Emergency Medicine, Turkey
| | - Mustafa Kesapli
- Antalya Training and Research Hospital, Department of Emergency Medicine, Turkey
| | - Ahmet Celik
- Antalya Training and Research Hospital, Department of Emergency Medicine, Turkey
| | - Adeviye Karaca
- Antalya Training and Research Hospital, Department of Emergency Medicine, Turkey
| | - Mehmet Nuri Bozdemir
- Antalya Training and Research Hospital, Department of Emergency Medicine, Turkey
| | - Cenker Eken
- Akdeniz University Medical Faculty, Department of Emergency Medicine, Turkey
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O'Brien HL, Kabbouche MA, Kacperski J, Hershey AD. Treatment of pediatric migraine. Curr Treat Options Neurol 2015; 17:326. [PMID: 25617222 DOI: 10.1007/s11940-014-0326-1] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
OPINION STATEMENT The diagnosis of migraine in the pediatric population is increasing as providers are becoming more familiar with recognizing the condition. Over-the-counter and migraine-specific treatment, once considered off-label, have proven to be effective, especially if given at the early onset of head pain. Mild to severe cases of migraine should be treated with nonsteroidal anti-inflammatory drugs (NSAIDs), with triptans used alone or in combination in moderate to severe headaches unresponsive to over-the-counter therapy. Rescue medication including dihydroergotamine (DHE), a potent vasoconstrictor should be used for intractable migraines and is preferred in the hospital setting. Anti-emetics that have anti-dopaminergic properties can be helpful in patients with associated symptoms of nausea and vomiting along with headache, especially when used in combination therapy. Preventative treatment should be initiated early in patients with frequent headaches to improve headache outcomes and quality of life. Patients and families should be educated on non-pharmacologic management, such as lifestyle modification and avoidance of triggers, that can prevent progression and worsening of migraine.
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Affiliation(s)
- Hope L O'Brien
- Division of Neurology, Cincinnati Children's Hospital Medical Center, 3333 Burnett Avenue, Cincinnati, OH, 45229, USA,
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O'Brien HL, Kabbouche MA, Hershey AD. Treating pediatric migraine: an expert opinion. Expert Opin Pharmacother 2012; 13:959-66. [PMID: 22500646 DOI: 10.1517/14656566.2012.677434] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
INTRODUCTION Headaches are common in children and adolescents and migraine affects almost 8% of this population. As revisions are made to the ICHD-II criteria to include additional characteristics of pediatric migraine, the diagnosis of migraine is expected to increase. Therefore, it is important to understand and apply successful treatment in acute migraine. Patients and families should be educated about the options for migraine treatment that includes both pharmacologic and conservative behavioral techniques in managing headaches. AREAS COVERED This review examines the studies that have been performed in pediatric patients, in addition to exploring the treatment options commonly used in pediatrics and adolescents for migraine and their rationale for use. EXPERT OPINION For the acute treatment of migraine, we recommend the use of ibuprofen or acetaminophen for mild, moderate or severe headache. For moderate to severe headache, or for headaches that fail to respond to over-the-counter medications, we recommend the use of a triptan or combination NSAID/triptan therapy. For preventative treament of migraine, cyproheptadine should be reserved for younger children unable to swallow tablets while amitriptyline is preferred due to its once daily dosing and minimal side effects. Topiramate and divalproate are considerable options depending on patient co-morbid profile and preference.
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Affiliation(s)
- Hope L O'Brien
- Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229, USA
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Abstract
A major potential goal of burn therapy is to limit progression of partial- to full-thickness burns. To better test therapies, the authors developed and validated a vertical progression porcine burn model in which partial-thickness burns treated with an occlusive dressing convert to full-thickness burns that heal with scarring and wound contraction. Forty contact burns were created on the backs and flanks of two young swine using a 150 g aluminum bar preheated to 70°C, 80°C, or 90°C for 20 or 30 seconds. The necrotic epidermis was removed and the burns were covered with a polyurethane occlusive dressing. Burns were photographed at 1, 24, and 48 hours as well as at 7, 14, 21, and 28 days postinjury. Full-thickness biopsies were obtained at 1, 4, 24, and 48 hours as well as at 7 and 28 days. The primary outcomes were presence of deep contracted scars and wound area 28 days after injury. Secondary outcomes were depth of injury, reepithelialization, and depth of scars. Data were compared across burn conditions using analysis of variance and χ(2) tests. Eight replicate burns were created with the aluminum bar using the following temperature/contact-time combinations: 70/20, 70/30, 80/20, 80/30, and 90/20. The percentage of burns healing with contracted scars were 70/20, 0%; 70/30, 25%; 80/20, 50%; 80/30, 75%; and 90/20, 100% (P = .05). Wound areas at 28 days by injury conditions were 70/20, 8.1 cm(2); 70/30, 7.8 cm(2); 80/20, 6.6 cm(2); 80/30, 4.9 cm(2); and 90/20, 4.8 cm(2) (P = .007). Depth of injury judged by depth of endothelial damage for the 80/20 and 80/30 burns at 1 hour was 36% and 60% of the dermal thickness, respectively. The depth of injury to the endothelial cells 1 hour after injury was inversely correlated with the degree of scar area (Pearson's correlation r = -.71, P < .001). Exposure of porcine skin to an aluminum bar preheated to 80°C for 20 or 30 seconds results initially in a partial-thickness burn that when treated with an occlusive dressing progresses to a full-thickness injury and heals with significant scarring and wound contracture.
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Reepithelialization of Mid-dermal Porcine Burns After Rapid Enzymatic Debridement With Debrase®. J Burn Care Res 2011; 32:647-53. [DOI: 10.1097/bcr.0b013e31822dc467] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Abstract
OPINION STATEMENT The recognition of the diagnosis of migraine in the pediatric population is increasing. Early and aggressive treatment of migraine in children and adolescents with the use of over-the-counter medications has proven effective. In addition, the off-label use of many migraine-specific medications is often accepted in the absence of sufficient evidence-based trials. Mild to severe cases of migraine should be treated with NSAIDs, with triptans used for moderate to severe headaches that are unresponsive to over-the-counter therapy. Rescue medication including dihydroergotamine (DHE) should be used for intractable migraines, preferably in the hospital setting. In patients with associated symptoms of nausea and vomiting, antiemetics with antidopaminergic properties can be helpful through their action on central migraine generation. Furthermore, patients and families should be educated about nonpharmacologic aspects of management such as preventing episodic migraine through lifestyle modification and avoidance of triggers.
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Affiliation(s)
- Andrew D Hershey
- Department of Pediatrics, University of Cincinnati, College of Medicine and Division of Neurology, Cincinnati Children's Hospital Medical Center, USA
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Kabbouche MA, Cleves C. Evaluation and management of children and adolescents presenting with an acute setting. Semin Pediatr Neurol 2010; 17:105-8. [PMID: 20541102 DOI: 10.1016/j.spen.2010.04.004] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Headache is the third leading cause of referral to a pediatric emergency room. It is imperative for providers to be able to rule out rare but possible life-threatening disorders, such as meningitis, intracranial hemorrhage, brain tumor, or hydrocephalus. Most of the presenting headaches are secondary to viral illnesses followed by primary headache and migraine. A detailed initial evaluation is essential to guide toward necessary testing as well as diagnosis.
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Abstract
Headaches in children and adolescents are still under-diagnosed. 75% of children are affected by primary headache by the age of 15 with 28% fitting the ICHD2 criteria of migraine. Migraine is considered a chronic disorder that can severely impact a child's daily activities, including schooling and socializing. Early recognition and aggressive therapy, with acute and prophylactic treatments, as well as intensive biobehavioral interventions, are essential to control the migraine attacks and reverse the progression into intractable disabling headache.
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Affiliation(s)
- Marielle A Kabbouche
- Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, Division of Neurology, MLC #2015, 3333 Burnet Avenue, Cincinnati, OH, USA.
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Singer AJ, McClain SA, Hacht G, Batchkina G, Simon M. Semapimod Reduces the Depth of Injury Resulting in Enhanced Re-epithelialization of Partial-Thickness Burns in Swine. J Burn Care Res 2006; 27:40-9. [PMID: 16566536 DOI: 10.1097/01.bcr.0000194276.36691.fb] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Studies suggest that tumor necrosis factor alpha (TNF-alpha) plays a role in burn pathogenesis. We conducted a randomized controlled experiment in swine to determine whether a novel macrophage inhibitor, semapimod (formerly known as CNI-1493), would blunt the local production of TNF-alpha, interleukin (IL)-1, and IL-6 in burns leading to less injury extension and faster re-epithelialization. After creating second-degree burns, animals received one or two intravenous boluses of semapimod 1 mg/kg or normal saline, and all burns were treated with silver sulfadiazine. The depth of follicular necrosis and thrombosis was reduced by either one or two doses of semapimod (P=.04 and .02, respectively). However, no differences were noted between groups in cytokine levels. Depth of scarring was similar in all groups. We conclude that Semapimod reduces the depth of follicular necrosis and thrombosis after second-degree burns in swine, indirectly resulting in more rapid re-epithelialization. However, this affect does not appear to be mediated by reduced local TNF-alpha, IL-1, or IL-6 protein levels.
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Affiliation(s)
- Adam J Singer
- Department of Emergency Medicine, Stony Brook University, Stony Brook, New York 11794-8350, USA
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Kabbouche MA, Linder SL. Management of migraine in children and adolescents in the emergency department and inpatient setting. Curr Pain Headache Rep 2005; 9:363-7. [PMID: 16157067 DOI: 10.1007/s11916-005-0014-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Migraine is a chronic disorder that can be debilitating, especially when the attacks are severe and frequent. Children and adolescents are significantly affected. The prevalence of migraine in this age group is higher than predicted due to more recognition of the disease in this population throughout the past century. Severe chronic migraine can cause failure in academic work and may lead to depression. Multiple medications are used to break an acute attack. Most approaches are based on outpatient treatments and include the use of over-the-counter medications and triptans and narcotics. This manuscript reviews most of the available therapies for acute treatment of primary headache that did not respond to outpatient management.
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Affiliation(s)
- Marielle A Kabbouche
- Division of Neurology, Cincinnati Children's Hospital Medical Center, Headache Center, MLC #2015, Cincinnati, OH 45229-3039, USA.
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Abstract
Migraine headache can be debilitating. If initiated early, aggressive management may prevent severe disability and failure at school. It must be noted that treatments available for use for acute migraine headache in children and adolescents are off-label. Their use is widespread, but double-blind, placebo-controlled studies are still unavailable for this age group.
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Affiliation(s)
- Marielle A Kabbouche
- Division of Neurology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229-3039, USA.
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Miner JR, Fish SJ, Smith SW, Biros MH. Droperidol vs. prochlorperazine for benign headaches in the emergency department. Acad Emerg Med 2001; 8:873-9. [PMID: 11535479 DOI: 10.1111/j.1553-2712.2001.tb01147.x] [Citation(s) in RCA: 70] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVE To compare the efficacy of droperidol with that of prochlorperazine for the treatment of benign headaches in emergency department (ED) patients. METHODS Prospective, randomized clinical trial in an urban ED. Patients were given either droperidol, 5 mg intramuscular (IM) or 2.5 mg intravenous (IV), or prochlorperazine, 10 mg IM or 10 mg IV. Measurements included side effects and the patient's pain perception as measured on a 100-mm visual analog scale (VAS) at baseline, 30, and 60 minutes after the medication was given. Data were analyzed using chi-square, two-tailed t-tests, and two-way analysis of variance (ANOVA) when appropriate. RESULTS During an eight-month period, 168 patients were enrolled. Eighty-two (48.8%) of the patients received droperidol; 86 (51.2%) received prochlorperazine. In the droperidol group, 49 (59.6%) received IM administration and 33 (40.4%) IV. In the prochlorperazine group, 57 (66.3%) received IM administration and 29 (33.7%) IV. Sixty minutes after the medication, the mean decrease in the VAS scores was 81.4% for droperidol and 66.9% for prochlorperazine (p = 0.001). At 30 minutes, 60.9% of the patients receiving droperidol and 44.2% of the patients receiving prochlorperazine had obtained at least a 50% reduction in their VAS scores (p = 0.09). At 60 minutes, 90.2% of the patients receiving droperidol and 68.6% of the patients receiving prochlorperazine had at least a 50% reduction in their VAS scores (p = 0.017). No difference between IM dosing and IV dosing was detected. Side effects, including dystonia, akathisia, and decreased level of consciousness, were seen in 15.2% of the patients receiving droperidol and 9.61% of the patients receiving prochlorperazine. No significant or persisting morbidity was detected. CONCLUSIONS Droperidol was more effective than prochlorperazine in relieving pain associated with benign headaches.
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Affiliation(s)
- J R Miner
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, MN 55415, USA.
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