TOP 16 - Comparing Second-Line Intravenous Medication Management of Acute Migraine Headache in the Pediatric Emergency Department: Magnesium vs. Methylprednisolone

Publication Number: 4718.TOP 16

Radhika Ghodasara, Cohen Children's Medical Center, Brooklyn, NY, United States; Kristy Williamson, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Garden City, NY, United States; Isabella Yu, Northwell Health, New Hyde Park, NY, United States; Joanna Fishbein, Northwell Health, Plainview, NY, United States

Background: Migraines in children are the most common primary headache disorders in the Pediatric Emergency Department (PED). Migraine pain refractory to outpatient and oral interventions often warrants treatment with intravenous (IV) medications. Definitive, evidence-based guidelines of IV management for pediatric acute migraine in the emergency setting is lacking, and much of pediatric migraine management is guided by extrapolated adult data and expert opinion. Commonly used and better reviewed IV medications for pediatric migraine include NSAIDs (ketorolac) and dopamine receptor antagonists (metoclopramide, prochlorperazine), often given in combination with fluids as a first-line IV “migraine cocktail”. Some patients require second-line IV medication due to refractory pain. The evidence for second-line IV medication management of pediatric acute migraine is even more sparse, leading to significant treatment variability. Steroids and magnesium are two classes of second-line IV migraine treatment that are used in the PED setting.

Objective: This study aims to compare two IV medications, magnesium sulfate and methylprednisolone, as second-line migraine abortive agents and assess if one is significantly better at improving pediatric migraine headache pain refractory to standard first-line IV treatment in the PED.

Design/Methods: This is an IRB exempt, retrospective chart review of 55 subjects ages 6 to 18 years presenting to the PED at Cohen Children's Medical Center between September 23, 2022 and July 30, 2025. These patients were treated for migraine headache or probable migraine as per the institutional guideline for pediatric acute migraine management whose pain was refractory to the standard first-line IV treatment “migraine cocktail” and thus received a second-line IV treatment of either methylprednisolone or magnesium sulfate. The choice of second-line medication is based on provider preference, as the guideline offers either option for providers to administer. The primary outcome for this study was clinically significant improvement of migraine pain as defined by a numeric rating scale pain score improvement of ≥ 2 points, qualitative clinical pain improvement, or discharge from ED following administration of the second-line medication. Secondary outcome data included disposition from the PED, adverse medication events, need for additional migraine medications following second-line treatment, and re-visit to PED within 72 hours for migraine. Statistical analysis will be carried out using Chi-Square tests, Wilcoxon rank sum tests, and logistic regression, as appropriate.