Headache disorders such as status migrainosus are a cause of significant burdens, including disability, missed days of school, impacts on quality of life and financial cost. Migraines account for 18% of pediatric emergency room visits.
"The hallmark symptoms for migraine in the pediatric population are similar to adults," said Paul Drake, M.D., pediatric neurologist at Arkansas Children's Neurology Headache Clinic. "It's usually this pounding headache with light sensitivity, sound sensitivity, nausea and sometimes vomiting."
In status migrainosus, migraine symptoms persist for 72 hours or longer. Parents of these children are concerned with the level of pain and are often just as concerned about the level of disability. Pediatric status migrainosus sufferers often are stuck in a vicious cycle of missing school and catching up on schoolwork. Headaches affect their ability to participate in activities and their quality of life.
Pediatric neurology specialists at the headache clinic try home abortive treatments first, but stubborn, intractable headaches refractory to treatment require an IV infusion for relief and restored function. Typically performed at the emergency room, the Arkansas Children's Hospital Neurology Headache Clinic recognized that an outpatient IV infusion protocol for intractable headaches would enable timelier care for pediatric headache sufferers.
"We developed an ER headache pathway a couple of years ago to better streamline management of migraine patients in the ER," Dr. Drake said. "We modeled the infusion clinic after that pathway; we offer the same medications that patients get when they come to the ER."
Patients at Arkansas Children's Hospital's Neurology Headache Clinic with an established diagnosis can use the new infusion protocol. Patients must be seen by a pediatric neurologist at the headache clinic first for screening, evaluation and any necessary workup to rule out secondary causes of headaches before being scheduled at the infusion center. The headache clinic also screens for sleep disorders and mood disturbances. Outside providers should first refer patients with complex headaches to Arkansas Children's Hospital Neurology Headache Clinic for consultation.
Patients who have headaches with the same characteristics they have previously described during office visits at the headache clinic can use the infusion center. The pathway includes screening questions to rule out the need for emergency room evaluation, such as head trauma or symptoms that do not typically accompany their headaches.
The infusion protocol is a three-tiered approach designed so that infusion nurses can go through the pathway while communicating with the patient's pediatric neurologist. Each tier involves specific medications proven to treat status migrainosus.
If the patient's headache aborts after tier one, nurses at the infusion center communicate this to the pediatric neurologist. If the headache does not return following one hour of monitoring, the patient is discharged without seeing a provider. If the headache does not abort or returns following tier one of the protocol, the nurses obtain approval to proceed to tier two and then tier three, if needed. The average time at the infusion center is about half of a typical ER visit for pediatric headache sufferers, resulting in earlier relief and restored function.
The infusion center offers same-day appointments if the patient can arrive by 2 p.m. due to time constraints typically associated with outpatient clinic hours. Since Arkansas Children's Hospital is the only pediatric headache clinic in the state, sometimes transportation can be a limiting factor. If the timing of the headache or travel time does not allow for a same-day appointment, the patient can be seen at the infusion center the next morning or go to their local ER.
"We developed an ER headache pathway to better streamline management of migraine patients in the ER, and we modeled the infusion clinic after that pathway. The infusion center allows us to offer established patients a same-day appointment, improving the quality of care dramatically and resulting in less time away from school."