Similar Presentations, Divergent Clinical Courses

BACKGROUND: Pediatric emergency department (ED) headache presentations may follow heterogeneous clinical courses. OBJECTIVE: To compare presentation characteristics, migraine order-set activation, pain-score change, treatment intensity, and health care utilization between pediatric ED headache encounters with and without a clinician-documented persistent/intractable headache. METHODS: We conducted a multisite retrospective cross-sectional study of children aged 3 to 18 years presenting to 2 pediatric EDs with headache or migraine as a chief complaint from 2019 to 2023. Encounters were classified by clinician documentation of an intractable/refractory headache diagnosis or persistent symptoms despite initial treatment. The primary outcome was change from arrival to posttreatment/disposition pain score. Sensitivity analyses were restricted to each patient's first encounter and to clinician-documented migraine or status migrainosus. RESULTS: Among 529 encounters, 18.5% had a documented persistent/intractable headache course. Most presentation characteristics were similar, although symptom duration and pulmonary comorbidity differed. Order-set activation did not differ significantly (76.5% vs. 68.2%; P = 0.106). Encounters with a persistent/intractable headache had less pain improvement [median: -4 (interquartile range: -6.75 to -1) vs. -5 (interquartile range: -7 to -3); P = 0.002], received more medications, radiologic imaging (39.8% vs. 26%; P = 0.006), neurology consultation (56.1% vs. 39.4%; P = 0.003), hospitalization (19.4% vs. 3.2%; P < 0.001), and 30-day return ED visits (10.2% vs. 4.6%; P = 0.049). The pain-score difference was attenuated in the first-encounter analysis (P = 0.060), but persisted in the clinician-documented migraine subgroup (P = 0.006). CONCLUSION: Headache presentation characteristics and order-set activation did not distinguish the ED course, but pain improvement, treatment intensity, and utilization differed during ED care. Prospective studies should evaluate standardized early reassessment measures.