Enhancing Outpatient Dihydroergotamine Infusion With Interdisciplinary Care to Treat Refractory Pediatric Migraine: Preliminary Outcomes From the Comprehensive Aggressive Migraine Protocol (“CAMP”)

Abstract

ObjectiveTo determine preliminary outcomes of a treatment for refractory pediatric migraine that integrates outpatient dihydroergotamine (DHE) infusion with interdisciplinary adjunctive care.BackgroundLimited data are available to inform treatment of refractory migraine in children. Intravenous DHE therapy has shown promise but has been implemented in costly inpatient settings and in isolation of nonpharmacological strategies shown to enhance analgesia and functional improvement.MethodsWe conducted a retrospective chart review of 36 patients ages 11‐18 with refractory migraine who underwent a pilot treatment program in an outpatient neurology clinic. The treatment integrated up to 5 days of outpatient DHE infusion with adjunctive nonpharmacological care (pain coping skills training, massage, aromatherapy, and school reintegration support). Changes in headache, healthcare utilization, and functional limitations were assessed as indicators of treatment response through 3‐month follow‐up.ResultsOn average, headache intensity declined (M = 5.8 ± 2.5 to M = 2.4 ± 2.7; P < .0001) during the treatment period and remained statistically significantly improved through 3‐month follow‐up. Headache frequency decreased by a mean of 1.5 days per week (M = 6.7 ± 1.0 vs M = 5.2 ± 2.7, P = .012) through 3‐month follow‐up, with a 27% reduction (from 0.91 to 0.66) in the proportion of patients reporting a continuous headache (P = .009). Over this same follow‐up period, there was a reduction in school days missed per month (median [25th, 75th percentile]: 4.5 [0, 21.0] vs 0 [0.0, 0.5]). There also were reductions in headache‐related visits per month to the emergency department and medical providers. Adverse effects were common but typically minor and transient.ConclusionsCombining outpatient DHE infusion with interdisciplinary adjunctive care has promise as an effective treatment option for adolescents with refractory migraine.

Implementation of an Intravenous Dihydroergotamine Protocol for Refractory Migraine in Children

“…These factors would be of interest in future data analyses as we continue our efforts to improve our inpatient IV DHE protocol, and one approach to improving its long‐term benefit may be to use the inpatient admission as an opportunity to implement a more comprehensive assessment and intervention. The encouraging preliminary results of a recent pilot program incorporating IV DHE and adjunctive non‐pharmacological care, including psychological assessment, strategies to cope with pain, stress management, relaxation skills, therapeutic massage, and social work support for school reintegration, suggest that this represents an important area of future investigation 10 . Connelly et al reported that participants experienced an average decrease in pain intensity of 58% by the conclusion of the 5‐day program and 33% achieved headache freedom, but most importantly, unlike our experience with IV DHE alone, participants continued to report decreased headache intensity and frequency by their 3‐months follow‐up 10 …”

<p>Updated Evaluation of IV Dihydroergotamine (DHE) for Refractory Migraine: Patient Selection and Special Considerations</p>

“…22 IV DHE has been shown to be effective in status migrainosus in children and adolescents. [23][24][25] There are two inpatient dosing schedules for pediatric patients described in the literature, based on weight, age, and tolerability. A lower dose protocol calls for 0.1-0.2 mg/dose (based on age) along with a neuroleptic (eg, metoclopramide) administered every 6 hours for a maximum of 16 doses or until headache freedom is achieved.…”

Standardized Headache Therapy in the Pediatric Emergency Department Using Improvement Methodology

“…We anticipate that, absent adverse outcomes, patients with improved pain scores or the resolution of headache can be discharged from the PED, similar to infusion center protocols. 22 …”

“…Additionally, we aimed to implement a new process for delivering DHE in the PED to patients who failed initial parenteral abortive therapy. We chose this therapy strategy given its application in our outpatient headache infusion center, emerging evidence supporting its outpatient use, 22 and the theory that earlier initiation of DHE might improve headache time course for admitted patients, resulting in shorter inpatient LOS.…”