• Migraine diagnosis should only be made after other serious intracranial diagnoses have been ruled out.
• Pediatric migraine is a difficult diagnosis to make before the age of 7 years, due to communication difficulties
• Avoid opiates and barbiturates. They have not proven to be effective, and have been shown to decrease the effectiveness of future triptan treatments. 
• First line treatment for mild to moderate migraines is acetaminophen and/or NSAID's.  The addition of caffeine, has been shown to potentiate the analgesic effects of both.
• First line treatment for moderate to severe migraines is triptans.
• Most pediatric migraines presenting to the ED, are severe migraines that have failed the above abortive home treatments and have persisted for 24+ hours.  These patients often require intravenous therapy.
• Dopamine receptor antagonist, specifically Prochlorperazine, 0.15mg/kg, 10mg max, has demonstrated the greatest effectiveness. Consider administration with diphenhydramine, 1mg/kg, 50mg max to prevent dystonic reactions.
• Concomitant dexamethasone, 0.6mg/kg, 20mg max administration has been shown to decrease acute recurrence.
• If prochlorperazine fails, other alternatives include Sumatriptan, 5-20mg IN, 50-100mg PO and lidocaine, 0.5mL of 4% solution IN.
• IVF hydration, and reduction of light and sound stimuli may be helpful.

References

Bachur, R. Comparison of acute treatment regimens for migraine in the emergency department. Pediatrics.2015;135(2)232-238.

Gelfand, A. Treatment of pediatric migraine in the emregency department. Ped Neuro.2012;47(4)233-241.

Kacperski, J. The optimal management of headaches in chidlren and adolescents. Ther Adv Neuro Disor. 2016;9(1)53-68.

Sheridan, D. Pediatric Migraine: Abortive treatment in the emergency department. Headache. 2014;54(2):235-245.