SGEM#378: Keepin’ It REaL when Treating Pediatric Migraine Patients

Date: September 28th, 2022 Reference: Hartford et al. Disparities in the emergency department management of pediatric migraine by race, ethnicity, and language preference. AEM September 2022. Guest Skeptic: Dr. Lauren Westafer is an Assistant Professor in the Department of Emergency Medicine at the University of Massachusetts Medical School – Baystate. She is the cofounder of FOAMcast and is a pulmonary embolism and implementation science researcher. Case: A 15-year-old patient presents to the Emergency Department with a unilateral pounding headache. The headache is similar to prior migraine headaches. They have photophobia but no vision changes, weakness, numbness, tingling, or neurologic deficits. They took 400 mg ibuprofen at home without relief. The patient and their mother ask what the next steps will be and what type of medication will be administered. Background: We have looked at migraine treatment a few times on the SGEM. That includes an episode on steroids to prevent bounce back visits to the ED (SGEM#28), ketorolac for acute treatment (SGEM#66), acupuncture for prophylaxis (SGEM#211) and a calcitonin gene-related peptide antagonist (SGEM#279). Patients with migraines often present to the ED looking for pain relief. There are many therapeutic options available to clinicians to address their pain. Unfortunately, poor pain control persists despite the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) making pain “the fifth vital sign” in 2001 to raise the awareness of oligoanalgesia in the ED. Despite the limitation of having a subjective measure as a vital sign, the problem of oligoanalgesia (poor pain management) persists (Motov and Khan). Some groups of patients who are at greater risk than others (elderly, women, mentally ill, certain ethnic groups, and insurance status). Children represent one group that is less likely to receive adequate analgesia. (Brown et al, Selbst and Clark). It is not well documented, whether gaps in pain assessment and treatment exist in conditions in which opioids are not indicated, such as migraine headaches. It is hypothesized that race, ethnicity and language (REaL) could also be independently associated with pain control. Clinical Question: Is there an association between patient demographics (race, ethnicity, and language) and pain management among pediatric ED patients presenting with migraine headaches? Reference: Hartford et al. Disparities in the emergency department management of pediatric migraine by race, ethnicity, and language preference. AEM September 2022. Population: All patients treated in a single pediatric ED with at least one migraine-relevant medication using an ED migraine pathway from pathway inception (October 14, 2016) through February 28, 2020. Excluded: Repeat encounters Intervention: Intravenous (IV) medications +/- oral (PO)/intranasal (IN) Comparison: Oral or intranasal medications only Outcome: Primary Outcome: Treatment group assignment according to race, ethnicity and language (REaL) categories. Secondary Outcomes: Pain intensity scores using the age-appropriate scale (FACES or 0-10 pain scale), ED length of stay, ED charges (billing data) Dr. Emily Hartford This is an SGEMHOP episode which means we have the lead author on the show. Dr. Emily Hartford is as assistant professor in Pediatric Emergency Medicine at the University of Washington and Seattle Children’s Hospital.  She works to improve equity for patients of diverse backgrounds in the ED as well as in global partnerships to improve pediatric emergency education. This study was part of a quality improvement project that involved a migraine protocol (see below). Authors’ Conclusions: “In this retrospective analysis of pediatric migraine patients in the ED, we found that race/ethnicity and language for care were significantly associated with odds of receiving intravenous therapies compared to oral or intrana...