{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,12]],"date-time":"2026-10-12T06:45:41Z","timestamp":1791787541730,"version":"4.3.4"},"reference-count":37,"publisher":"Ovid Technologies (Wolters Kluwer Health)","content-domain":{"domain":["lww.com","ovid.com"],"crossmark-restriction":true},"short-container-title":[],"abstract":"\n Background:<\/jats:title>\n Pediatric emergency department (ED) headache presentations may follow heterogeneous clinical courses.<\/jats:p>\n <\/jats:sec>\n \n Objective:<\/jats:title>\n 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.<\/jats:p>\n <\/jats:sec>\n \n Methods:<\/jats:title>\n 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\u2019s first encounter and to clinician-documented migraine or status migrainosus.<\/jats:p>\n <\/jats:sec>\n \n Results:<\/jats:title>\n \n 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%;\n P<\/jats:italic>\n = 0.106). Encounters with a persistent\/intractable headache had less pain improvement [median: \u22124 (interquartile range: \u22126.75 to \u22121) vs. \u22125 (interquartile range: \u22127 to \u22123);\n P<\/jats:italic>\n = 0.002], received more medications, radiologic imaging (39.8% vs. 26%;\n P<\/jats:italic>\n = 0.006), neurology consultation (56.1% vs. 39.4%;\n P<\/jats:italic>\n = 0.003), hospitalization (19.4% vs. 3.2%;\n P<\/jats:italic>\n < 0.001), and 30-day return ED visits (10.2% vs. 4.6%;\n P<\/jats:italic>\n = 0.049). The pain-score difference was attenuated in the first-encounter analysis (\n P<\/jats:italic>\n = 0.060), but persisted in the clinician-documented migraine subgroup (\n P<\/jats:italic>\n = 0.006).\n <\/jats:p>\n <\/jats:sec>\n \n Conclusion:<\/jats:title>\n 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.<\/jats:p>\n <\/jats:sec>","DOI":"10.1097\/pec.0000000000003732","type":"journal-article","created":{"date-parts":[[2026,10,12]],"date-time":"2026-10-12T06:00:15Z","timestamp":1791784815000},"update-policy":"https:\/\/doi.org\/10.1097\/lww.0000000000001000","source":"Crossref","is-referenced-by-count":0,"title":["Similar Presentations, Divergent Clinical Courses"],"prefix":"10.1097","author":[{"given":"Suvleen","family":"Singh","sequence":"first","affiliation":[{"name":"University of Central Florida, College of Medicine"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Alejandro","family":"Ramirez","sequence":"additional","affiliation":[{"name":"Ginsburg Institute for Health Equity"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-8423-3981","authenticated-orcid":false,"given":"Andrea","family":"Rivera-Sepulveda","sequence":"additional","affiliation":[{"name":"Department of Pediatrics, Nemours Children\u2019s Health, Orlando, FL"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"276","published-online":{"date-parts":[[2026,10,12]]},"reference":[{"key":"R1-20261012","doi-asserted-by":"crossref","first-page":"280","DOI":"10.3390\/brainsci15030280","article-title":"Current trends in pediatric migraine: clinical insights and therapeutic strategies","volume":"15","author":"Khan","year":"2025","journal-title":"Brain Sci"},{"key":"R2-20261012","doi-asserted-by":"crossref","first-page":"76","DOI":"10.1016\/j.acap.2022.04.007","article-title":"Disparities and trends in migraine management in pediatric emergency departments, 2009\u201319","volume":"23","author":"Genadry","year":"2023","journal-title":"Academic Pediatrics"},{"key":"R4-20261012","first-page":"487","article-title":"Practice guideline update summary: acute treatment of migraine in children and adolescents: report of the Guideline Development, Dissemination, and Implementation Subcommittee of the American Academy of","volume":"93","author":"Oskoui","year":"2019","journal-title":"Neurol Ame Headache Soc Neurol"},{"key":"R5-20261012","doi-asserted-by":"crossref","first-page":"104943","DOI":"10.1016\/j.ebiom.2023.104943","article-title":"Resistant and refractory migraine: clinical presentation, pathophysiology, and management","volume":"99","author":"Ornello","year":"2024","journal-title":"EBioMedicine"},{"key":"R6-20261012","doi-asserted-by":"crossref","first-page":"1263535","DOI":"10.3389\/fneur.2023.1263535","article-title":"Breaking the cycle: unraveling the diagnostic, pathophysiological and treatment challenges of refractory migraine","volume":"14","author":"Robblee","year":"2023","journal-title":"Front Neurol"},{"key":"R7-20261012","doi-asserted-by":"crossref","first-page":"89","DOI":"10.1186\/s10194-019-1040-x","article-title":"Identifying and managing refractory migraine: barriers and opportunities?","volume":"20","author":"D\u2019Antona","year":"2019","journal-title":"J Headache Pain"},{"key":"R8-20261012","first-page":"67853","article-title":"Review of interventional therapies for refractory pediatric migraine","volume":"10","author":"Peck","year":"2022","journal-title":"Health Psychol Res"},{"key":"R9-20261012","doi-asserted-by":"crossref","first-page":"77","DOI":"10.2147\/NSS.S34840","article-title":"Comorbidities of sleep disorders in childhood and adolescence: focus on migraine","volume":"5","author":"Bruni","year":"2013","journal-title":"NSS"},{"key":"R10-20261012","doi-asserted-by":"crossref","first-page":"52","DOI":"10.3390\/bs11040052","article-title":"Migraine and mood in children","volume":"11","author":"Gazerani","year":"2021","journal-title":"Behav Sci"},{"key":"R11-20261012","doi-asserted-by":"crossref","first-page":"e150","DOI":"10.1542\/peds.2009-2337","article-title":"Treatment of children with migraine in emergency departments: national practice variation study","volume":"126","author":"Richer","year":"2010","journal-title":"Pediatrics"},{"key":"R12-20261012","doi-asserted-by":"crossref","first-page":"e20163021","DOI":"10.1542\/peds.2016-3021","article-title":"Council on children with disabilities. 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