Acute treatment

The goal of acute therapy is to abort an attack of severe pain and suppress pain, nausea, and vomiting. For mild-moderate pain and minimal nausea, preferred agents are NSAIDs and paracetamol. For severe pain, opioids may be judiciously used, as well as nasal suma-triptan.103[II] As previously noted, we have little pediatric data regarding the safety and efficacy of subcutaneous sumatriptan and oral triptans.104[II] Adverse effects of the 5-HT 1B/1D receptor agonists include initial selective constriction of intracranial extracerebral vessels and inhibition of release of vasoactive neuropeptides from trigeminal nerve terminals in the intracranial vessels and meninges. Secondary effects include inhibition of noci-ceptive neurotransmission in the brain stem and cervical spinal descending trigeminal sensory nucleus.105 For nausea and vomiting, diphenhydramine and hydroxyzine are least associated with adverse effects, such as the mood changes and dystonia potentially seen with chlorproma-zine and metoclopramide. The dosing regimens shown in Table 44.3 are suggested for pediatric dosing.

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