589 - One Protocol, Two Phenotypes: Rethinking Standardized ED Pathways for Pediatric Migraine

Publication Number: 1566.589

Suvleen K.. Singh, University of Central Florida College of Medicine, Orlando, FL, United States; Alejandro Ramirez, University of North Carolina at Chapel Hill School of Medicine, Orlando, FL, United States; Andrea Rivera-Sepulveda, Nemours Children's Health, Orlando, FL, United States

Background: Pediatric migraine care in the emergency department (ED) often relies on a single, standardized protocol to expedite evaluation and treatment. However, migraine is a heterogeneous disorder; refractory and non-refractory cases often differ in pathophysiology, symptom burden, and treatment response. Applying a uniform protocol may streamline care but risks overlooking these key differences.

Objective: To evaluate whether a unified ED protocol achieves comparable outcomes among pediatric patients presenting with refractory and non-refractory migraine, focusing on pain reduction, resource utilization, length of stay (LOS), disposition, and 30-day return visits.

Design/Methods: We conducted a retrospective cross-sectional study of ED encounters from January 2019 to December 2023 across two freestanding children’s hospitals within a single healthcare system. Children aged 3–18 years presenting with a chief complaint of headache or migraine were included; medically complex patients, trauma cases, and charts with missing key data were excluded. Outcomes included change in pain score (arrival→disposition), ED LOS, diagnostic testing, medications administered (and repeats), hospital admission, and 30-day ED return. Group comparisons used chi-square and Mann–Whitney U tests and protocol effect was examined using ANCOVA with α=0.05.

Results: Of 629 encounters screened, 529 met inclusion criteria (81.5% non-refractory; 18.5% refractory). Protocol use was similar across groups. Pain reduction was greater for non-refractory patients treated with the standardized protocol (median −6 with protocol vs. −4 without; p< 0.001) but unchanged among refractory patients (median −4 with vs. −4 without; p=0.85). Refractory patients received more medications (median 4 vs. 3; p< 0.001), more repeat ketorolac (p=0.002), and were more likely to receive IV fluids (p=0.030), valproic acid (p < 0.001), and ondansetron (p=0.015). They also underwent more radiologic imaging and neurology consultations (both p< 0.01), had longer ED LOS (p < 0.001), higher admission rates (p < 0.001), and increased 30-day return visits (p=0.049).

Conclusion(s): A single standardized ED protocol effectively improves pain control in non-refractory pediatric migraine but plateaus in refractory disease, where care becomes medication-intensive, resource-heavy, and yields inferior outcomes. These findings underscore the need for adaptive, phenotype-aware clinical pathways that identify refractory migraine early, enable timely escalation beyond first-line therapies, and embed follow-up strategies to reduce recurrences and optimize outcomes for high-risk patients.