The management of acute pediatric migraine headaches in the pediatric emergency department (ED) and in a mixed pediatric and adult ED was compared at the University of Alberta, Edmonton, Canada. Of 382 patients identified with headache, aged 5 to 17 years, in 4 regional EDs during the 2003/2004 fiscal year, 186 (48.7%) met criteria for migraine. Simple oral analgesics in 20.7% and dopamine antagonists (metoclopramide and prochlorperazine) in 20.7% were prescribed first-line most commonly. Opiate medications (in 5.5%), ketorolac (4.7%), and dihydroergotamine (1%) were prescribed first-line infrequently. No treatment was given to 44.2%. The pediatric ED was more likely to prescribe a dopamine antagonist (12.9% vs 6.8%; P=0.044) while the mixed adult/pediatric EDs were significantly more likely to prescribe an opiate (28.1% vs 18.4%; P=0.031). Children with migraine in all EDs were significantly more likely to receive drug therapy (68.3% vs 42.9%; P<0.001) or a dopamine antagonist (32.3% vs 9.7%; P<0.001). Polypharmacy was used in 31.2%, and neuroimaging was obtained in 29.1%. In 109 studies, arachnoid cysts were diagnosed in 2 patients, optic glioma (1), sinus thrombosis (1), and sinusitis (1), a total of 5 (4.6%) abnormal scans. Lumbar puncture was performed in 9 patients (2.4%), with no difference between pediatric and adult cohorts. A headache associated infectious illness was diagnosed in 12%. Documentation of headache outcome was poor, but better in pediatric EDs compared with adult EDs (22.1% vs 13.6%). Complete headache resolution occurred in 13.9% and was significantly more common in the pediatric ED cohort compared with the adult ED cohort (20% vs 4%). 
COMMENT. Most children attending an ED in Canada with headache do not receive drug therapy. The type of medication most commonly prescribed is different in pediatric EDs compared to mixed adult/pediatric EDs. Dopamine antagonists are preferred in pediatric EDs and opiates in mixed EDs.