Low-dose propofol no more effective in children with migraines than standard treatment, but decreases time in ED

Liz Meszaros, MDLinx | March 12, 2018

In children with migraines, low-dose propofol was no more effective than standard therapy for pain relief, but was associated with significantly less likelihood of a rebound headache. Results were published in The Journal of Emergency Medicine.

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Pediatric migraine

Low-dose propofol should be used with caution in children presenting to the ED with migraine, but may reduce rebound headaches and length of stay.

Children treated with propofol also showed a trend toward shorter median length of stay in the pediatric emergency department (ED).

Parents often bring children with migraine to the ED for care. According to lead author David C. Sheridan, MD, MCR, assistant professor, Pediatric Emergency Medicine, and co-director IDEO-E.M., Oregon Health & Sciences University/Doernbecher Children’s Hospital, Portland, OR: “It is common that people try over the counter medications, and they just don't work. The other thing is many children have their first-time migraine and [with] no options at home to try, [they] come in.”

In this prospective, randomized, controlled trial, Dr. Sheridan and colleagues enrolled 66 children who presented to the ED at two pediatric hospitals from April 2014 to June 2016. Migraine was diagnosed by the emergency physician, and subjects were aged 7 to 19 years with a presenting visual analog pain score (VAS) of 6-10.

With standard therapy—comprised of ketorolac (nonsteroidal anti-inflammatory), compazine (dopamine antagonist), and diphenhydramine (anticholinergic) with IV fluids—pain was reduced by 59%, compared with 51% with propofol (P=0.34). With initial therapy, VAS ≤ 4 was achieved by 72.2% vs 73.3%, respectively (P=0.92). Children treated with standard therapy, however, were more likely to experience rebound headache compared with those treated with propofol (66.7% vs 25.0%; P=0.01).

Finally, children treated with propofol demonstrated a nonsignificant trend toward shorter median length of stay from administration of treatment to final ED release (79 minutes vs 111 minutes with standard therapy; P=0.09).

Dr. Sheridan urges caution, however, in children.

“The biggest risk is if a child got too much they can become sedated. For that reason, as our study says, it should only be used in the ER where doctors are credentialed and specially trained in sedation and use of these medications safely. It should never be used at home or in the clinic in our recommendation,” he told MDLinx.

“Standard therapy works for many children, but there is a group of them that it doesn't. A new alternative is low dose propofol in the ER setting, and it was shown in our study to work faster with less rebound headache at follow-up calls. For this reason, we would recommend it prior to considering admission for these children. The other take away is to NOT use opioid medications. Providers do this sometimes once standard therapy fails, but this shows there are other options available,” concluded Dr. Sheridan. 

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