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Treatment of status migrainosis with parenteral nsNSAIDs or steroids (usually dexamethasone)
is recommended (Evers et al, 2006; Steiner et al, 2007; Colman et al, 2008 Level I; Singh et al, 2008
Level I). IV droperidol was effective within 2 hours in 88% to 100% of patients with refractory
migraine or ‘status’ respectively; the recurrence rate within 24 hours was 10% to 23%.
Sedation or extrapyramidal symptoms (usually restlessness) developed in two‐thirds of
patients (Wang et al, 1997 Level IV).
Paediatric migraine
Migraine headaches are common in children and increase in frequency through to
adolescence from 3% (ages 3 to 6) to 8% to 23% (ages 11 to 16). General principles of
treatment are in accordance with adult migraine management but require due consideration
of paediatric pharmacological issues. Not all children require pharmacological intervention.
Medications shown to be effective in adults may not be appropriate for children, where
paediatric safety and efficacy studies have not been conducted.
Guidelines and evidence‐based reviews for the treatment of migraine in children and
adolescents have been promulgated (Lewis et al, 2004; Bailey & McManus, 2008 Level I; Silver et al,
2008 Level I).
In children, ibuprofen or paracetamol are recommended as first‐line treatments for acute
migraine. For adolescents (over 12 years of age), sumatriptan nasal spray is effective and
should be considered (Lewis et al 2004). Ibuprofen or sumatriptan were effective for relief
of headache (NNT 2.4 and 7.4 respectively) and complete pain relief (NNT 4.9 and 6.9
respectively) at 2 hours. Paracetamol, zolmitriptan, rizatriptan or dihydroergotamine were not
significantly better than placebo, but the number of RCTs in children is small (Silver et al, 2008
Level I). For adolescents (over 12 years of age), IN sumatriptan was effective, however the data
are limited and further studies are required (Damen et al, 2005 Level I).
A systematic review of migraine treatments for children in the emergency department found
only one RCT performed in this setting after other treatments had failed. This showed that
prochlorperazine was more effective than ketorolac; other RCTs reported that ibuprofen or
paracetamol were more effective than placebo; the data for triptans were unclear, with oral
sumatriptan or ergotamine being ineffective (Bailey & McManus, 2008 Level I).
CHAPTER 9 therapy, reduced the intensity of headache in children and treatment success could be
Psychological interventions, such as relaxation training, biofeedback and cognitive‐behavioural

maintained for at least 1 year, although comparative efficacy with pharmacological treatments
has not been investigated (Trautmann et al, 2006 Level I).
Menstruation-related migraine
Management of acute migraine during menstruation does not differ from treatment at
other times of the menstrual cycle, but prophylaxis is based on significant oestrogen and
progesterone fluctuations with appropriate hormone replacement, usually oestrodiol (Evers et
al, 2006). NsNSAIDs and triptans were effective in the treatment and prophylaxis of
menstruation‐related headaches (Evers et al, 2006). Menstruation‐related migraine was
effectively treated with an OTC combination of paracetamol, aspirin, and caffeine (Silberstein et
al, 1999 Level II).
Migraine in pregnancy and breastfeeding
Migraine can occur for the first time during pregnancy, and pre‐existing migraine may worsen,
particularly during the first trimester or the patient may become headache‐free later in
pregnancy. Approximately 60% to 70% of migraineurs improve during pregnancy. The true
incidence of migraine in pregnancy is uncertain and most cases are of migraine with aura
(Silberstein, 2001).

266 Acute Pain Management: Scientific Evidence