Pharmacologic Treatment of Acute Migraine in the Pediatric Emergency Department: A Systematic Review and Meta-analysis of Randomized Controlled Trials

Background Acute migraine is a frequent cause of pediatric emergency department (ED) visits, yet comparative evidence for pharmacologic management in this setting remains limited and heterogeneous. We conducted a systematic review and network meta-analysis of randomized controlled trials (RCTs) to compare the efficacy and safety of ED-based pharmacologic treatments for acute pediatric migraine. Methods We searched MEDLINE, Embase, CENTRAL, PubMed, Scopus, and Web of Science from inception to 2025 for RCTs evaluating acute pharmacologic therapies for migraine in patients < 18 years presenting to the ED. The primary outcome was pain response at 2 hours. Secondary outcomes included need for rescue therapy, ED length of stay, return visits, adverse events, and treatment satisfaction. Random-effects pairwise meta-analyses and a frequentist network meta-analysis were performed. Risk of bias was assessed using RoB 2, and certainty of evidence using GRADE. Results Nine RCTs involving 476 participants were included. Active ED migraine treatments were associated with a modest reduction in pain compared with control or standard care (mean difference of 5.96 points on a 0–100 scale; 95% CI 0.42 to 11.51), with low heterogeneity. The effect size was small and close to the minimal clinically important difference. Sensitivity analyses restricted to studies at moderate risk of bias showed no statistically significant benefit. Reporting of secondary outcomes and adverse events was inconsistent, precluding quantitative synthesis. Dopamine antagonists, particularly prochlorperazine, appeared more effective than NSAIDs for short-term pain relief but were associated with more extrapyramidal adverse effects. Conclusions Current pharmacologic treatments for acute pediatric migraine in the ED provide only modest short-term pain relief, with low-certainty evidence and no clearly superior therapy. Future large, multicenter ED-based trials with standardized, patient-centered outcomes and longer follow-up are needed to inform evidence-based care.