Sumatriptan as a First-Line Treatment for Headache in the Pediatric Emergency Department.

BACKGROUND: Headache is a common presenting condition for patients seen in the pediatric emergency department (ED). Intranasal (IN) sumatriptan is a well-tolerated and safe abortive treatment for migraine headache, but it is infrequently administered in pediatric EDs. In this study we characterize an ED migraine pathway that uses IN sumatriptan as a first-line treatment. METHODS: We performed retrospective chart analysis from a single center, reviewing a cohort of patients treated on an ED migraine pathway between October 2016 and February 2020. We reviewed patient demographics, clinical characteristics, treatment patterns, change in pain scores, sumatriptan prescriptions at discharge, length of stay (LOS), ED charges, and unexpected return visits. RESULTS: A total of 558 patients (aged six to 21 years, 66% female) were included in this study. Overall, the median pretreatment pain score was 7 (interquartile range [IQR]: 5 to 8) and the median post-treatment pain score was 2 (IQR: 0 to 4). Forty-eight percent of patients received IN sumatriptan in the ED, and 36% of those who received sumatriptan were prescribed oral sumatriptan at discharge. When intravenous (IV) access was obtained for headache management, this was associated with a significantly longer LOS and higher ED charges. CONCLUSIONS: IN sumatriptan shows promise as a feasible and potentially effective first-line treatment for pediatric migraine in the ED that could reduce the need for IV therapies, shorten LOS, and lower ED charges. Further research is needed to determine the efficacy of IN sumatriptan relative to other common first-line therapies used to treat pediatric migraine in the ED.

Resolution of a Focal Pruritic Rash Following Neurosurgical Decompression in an Adolescent With Chiari I and Syringomyelia.

BACKGROUND: Chiari I malformation (Chiari I) is defined by the downward displacement of one or both cerebellar tonsils below the foramen magnum of the skull with crowding altering cerebrospinal fluid flow. It can be associated with the development of a fluid-filled cavity within the spinal cord, syringomyelia. Neurological deficits or symptoms can occur at the level of anatomic involvement of syringomyelia. CASE PRESENTATION: A young man presented to dermatology clinic for evaluation of a pruritic rash. Recognizing a unique left "cape-like" distribution of neuropathic itch leading to prurigo nodularis, he was referred for further evaluation by neurology in the local emergency department. After additional history and neurological exam, a magnetic resonance imaging confirmed Chiari I with an associated syringobulbia and a syrinx extending to T10/11 of the spinal cord. Anteriorly the syrinx extended into the left parenchyma of his spinal cord involving the dorsal horn, a lesion explaining his neuropathic itch. The sensation of itch and rash resolved after posterior fossa craniectomy and C1 laminectomy with duraplasty. CONCLUSION: Neuropathic itch, in addition to pain, can be a symptom of Chiari I with syringomyelia. Focal pruritus without an obvious cutaneous trigger should prompt providers to consider a central neurological pathology. While many patients with Chiari I are asymptomatic, the presence of neurological deficits and syringomyelia, are indications for neurosurgical evaluation.

Disparities in the emergency department management of pediatric migraine by race, ethnicity, and language preference.

BACKGROUND: There are disparities in pain management for children presenting to the emergency department (ED) according to their racial and ethnic backgrounds. It is not known if there are differences in the treatment of pain associated with pediatric migraines by race, ethnicity, and language for care (REaL). METHODS: We analyzed treatment patterns and outcomes in our ED for acute migraine in pediatric patients by REaL. Retrospective data on treatments, length of stay (LOS), and charges were collected from the electronic medical record for pediatric patients on the ED migraine pathway from October 2016 to February 2020. Patient race/ethnicity and language for care were self-reported at registration. We analyzed two treatment groups: receipt of oral (PO) or intranasal (IN) medications only or intravenous (IV) ± IN/PO medications. A total of 833 patients (median age 14.8 years, interquartile range [IQR] 12.3-16.5 years; 67% female, 51% non-Hispanic White (nHW), 23% Hispanic, 8.3% Black or African American, 4.3% Asian) were included. A total of 287 received PO/IN medications only and 546 received IV medications. RESULTS: Initial pain scores in the two groups were similar. Patients who were Asian, Black or African American, and Hispanic or had a language for care other than English (LOE) had significantly lower odds of receiving IV treatment, while patients who were nHW and preferred English had higher odds of receiving IV treatment. The IV treatment group had longer LOS and ED charges. Pediatric ED patients with migraine who were Black, Asian, and Hispanic or had a LOE had a decreased likelihood of receiving IV therapies while patients who were nHW were more likely to receive IV treatments, despite similar initial pain scores. CONCLUSIONS: These data align with previous studies on pain management disparities and highlight another area where we must improve equity for patients in the ED.