Relative Effectiveness of Dopamine Antagonists for Pediatric Migraine in the Emergency Department

Pediatr Emerg Care. 2018 Mar;34(3):165-168. doi: 10.1097/PEC.0000000000000718.


Objective: Migraine headaches are common in the pediatric emergency department. The mainstay of abortive treatment consists of nonsteroidal anti-inflammatories and dopamine antagonists. The objective of this study was to compare the effectiveness of 3 commonly used dopamine antagonists to abort pediatric migraine.

Methods: This was a retrospective cohort study of all patients who presented to the pediatric emergency department at a tertiary care pediatric hospital between January 2010 and December 2013. Patients were treated for a migraine headache with a combination of ketorolac and one of the following dopamine antagonists: prochlorperazine, metoclopramide, or promethazine. The primary outcome was treatment failure and receiving non-evidence-based treatment defined by the need for opioids. Secondary outcomes included pain score reduction and return visit within 48 hours.

Results: There were 57 patients during this period with 67 visits that met inclusion criteria: 27 (40.3%) visits in which patients were treated with prochlorperazine, 23 (34.3%) visits in which patients were treated with metoclopramide, and 17 (25.4%) visits in which patients were treated with promethazine. Across visits, the mean age was 14.5 years, and 63% were women. Opioids were given for treatment failure in 8.7% of visits in which patients received prochlorperazine, 25% in which patients received metoclopramide, and 42.8% in which patients received promethazine. Patients treated with promethazine had significantly higher odds of needing opioids and experiencing less than 50% reduction in pain score compared with prochlorperazine after adjusting for patient characteristics.

Conclusions: This study suggests variable efficacy among 3 commonly used dopamine antagonists for pediatric migraine headache. Promethazine seems least effective and results in higher use of opioids compared with other available dopamine antagonists.

MeSH terms

  • Adolescent
  • Analgesics, Opioid / administration & dosage
  • Anti-Inflammatory Agents, Non-Steroidal / therapeutic use
  • Child
  • Cohort Studies
  • Dopamine Antagonists / therapeutic use*
  • Drug Therapy, Combination
  • Emergency Service, Hospital
  • Female
  • Humans
  • Ketorolac / therapeutic use
  • Male
  • Metoclopramide / therapeutic use*
  • Migraine Disorders / drug therapy*
  • Pain Measurement
  • Prochlorperazine / therapeutic use*
  • Promethazine / therapeutic use*
  • Retrospective Studies
  • Treatment Failure
  • Treatment Outcome


  • Analgesics, Opioid
  • Anti-Inflammatory Agents, Non-Steroidal
  • Dopamine Antagonists
  • Promethazine
  • Metoclopramide
  • Prochlorperazine
  • Ketorolac