By Jack Gladstein, M.D.
Director, Pediatric Headache Clinic, University of Maryland

Q. I have a youngster with migraine. Sometimes the pain is just terrible and she has nausea and vomiting, too. When should I bring her to the ER?

A. The emergency room, in general, is not the place to be when a youngster with migraine has a bad headache. It is generally noisy, filled with bright lights and commotion, and the triage and treating staff may not be sensitive to headache patients. Since ERs function under a “treat the patient who is sickest first” policy, a child with headache may be put on the bottom of the pile. As we all know, time wasted during a migraine may make it harder to treat, so waiting to be seen may make the headache refractory.

In the best case, you and your primary doctor will have already put into place a headache treatment regimen that includes preventive measures and acute treatment medications. Excellent headache plans also contain rescue contingencies so that you know what to do if first-line drugs don’t work.

Sometimes, despite the best of plans, a headache does not respond to an excellent treatment plan and the ER may be the next step. Reasons to come to the ER include:

  • A good outpatient plan did not work.
  • The youngster is dehydrated.
  • This headache is very different than most. For example, it came on very rapidly.
  • This is the first time the child has had neurological involvement, such as not walking or talking right, or a change in mental status.

In the ER, you must advocate for your youngster at triage, explaining that s/he has a history of migraine and that this attack has not responded to good treatment. This emergency should require prompt attention.

A healthcare professional will likely take a quick history and do a gentle exam, looking for anything that would hint at some problem besides migraine. Once the physician is reassured that it is a migraine, s/he will prescribe a plan that should include:

  • IV fluids
  • Migraine-specific medication
  • Anti-nausea medication

If this works, your youngster may go home with new medications to prevent the migraine from returning. These medications may include a triptan or steroids. Check back with your primary care doctor in the morning to adjust medications and consider next moves.

Q. What if my child has never been diagnosed with migraine?

A. Try to go to your primary care doctor for a diagnosis before finding yourself in the ER. Your healthcare professional will take a history and perform a physical exam, and then make a treatment plan tailored to your child. Migraine will be suspected if your child has a pattern of intermittent headaches, nausea, light or sound sensitivity and a need to rest during a headache. Once the diagnosis of migraine is suspected, then the ER is really needed only for the reasons described above.

However, if the headache is present all the time, or the headache frequency has changed, further workup may be warranted to rule out dangerous problems like tumors. Your primary care doctor may send you to the ER if s/he is worried about a serious cause. Tests that may be performed in the ER include a spinal tap or a CT scan. These are only needed if the ER physician is also concerned.

In most cases, a trip to the ER is unnecessary and a call to your primary care doctor can be informative and reassuring. If you do need to go, prepare your youngster with information about what to expect. This will make the trip less anxiety-provoking.