Timely Treatment for Eligible Patients with Acute Migraine

In 2023, 367 patients went to the Emergency Department (ED) at Cincinnati Children’s for acute migraine relief. Many had called the Headache Center first but were redirected to the ED because no infusion beds were available. In the ED, they were low triage priority and sometimes waited up to six hours for IV medication.

In response, the Headache Center team partnered with the Infusion Center and the James M. Anderson Center for Health Systems Excellence to initiate a quality improvement project, with the goal of helping eligible patients bypass the ED.

During the project, every established patient who called between 8–10 am and qualified for an infusion got an Infusion Center bed. There, in a quiet environment, patients received faster treatment from the headache team.

“The experience of being able to come into an infusion room was night and day different than going to the ER,” one family shared.

“What has helped most is consistency,” says Kelly Hayda, MSN, APRN-CNP, a headache nurse practitioner. “Now patients know that when they call, if they call by a certain time, we will most likely find them a bed.”

From ED Wait to Same-Day Infusion

The effort to move neurology acute care (NAC) out of the ED started nearly two decades ago. Because these patients didn’t have a trauma, infection or bleed, they ranked lower in ED triage. After trying several care settings, the Headache Center partnered with the Infusion Center and began to see some success.

Using process mapping, root-cause analysis, collaborative brainstorming and family interviews, the team built a set of targeted interventions at the Infusion Center that included:

• Daily NAC bed holds
• A single coordinator contact for admissions
• Pre-arrival telehealth visits
• Tracking every bed request
• A new NAC screening questionnaire (added January 2025)

How the Pathway Works

When patients experience a severe headache that they cannot treat at home, they follow this pathway:

1. The patient’s family calls the Headache Center.
2. A nurse uses a structured screening questionnaire to rule out secondary causes, such as infection or virus.
3. The patient’s most recent headache provider decides whether infusion is indicated.
4. The Headache Center coordinator books a reserved NAC bed at the Infusion Center on the Burnet Campus or Liberty Campus. Currently, the Infusion Center holds a bed at each location for headache patients from August through May. These are the months when headache visits peak with the school year, and when the ED is busiest.
5. A headache nurse practitioner completes a pre-infusion evaluation, sometimes by telehealth, before the patient arrives. They also place orders in advance.
6. Treatment begins on arrival and takes about two hours if there are no complications.

Built from Decades of Collaboration

Marielle Kabbouche Samaha, MD, director of the Headache Center, says Cincinnati Children’s was an early adopter of this approach. Now, multiple pediatric headache centers follow a similar model.

Collaboration among the Infusion Center, Neurology, the ED, the Anderson Center and access leadership has also been important. During the program’s growth, the teams met monthly. They worked through every problem that came up and how to prevent it in the future.

“That’s what really helped keep things going in the right direction,” says Hayda.

Now, patients receive treatment from headache experts, which reduces the chance of unnecessary imaging.

“It saves a lot of healthcare dollars because patients aren’t being assessed unnecessarily,” says Hayda. “In the ED, a resident or rotating physician may order a CT scan or workup to rule out other issues. We’re used to treating these patients and follow an algorithm that saves a lot of time and waiting in the ED.”

Future-Focused: Expanding Access and Research

Any Cincinnati Children’s neurologist can refer an established patient with migraine to the Infusion Center. But bed availability is still a limiting factor.

To expand capacity, the team began piloting home infusion in summer 2026. A nurse gives the treatment at home, which could keep some patients from needing to come in at all. The first case went well, and the team plans to expand the pilot in the coming year.

The team is also exploring other ways to expand capacity, including extended hours and direct ED-to-infusion admissions. The long-term goal is to serve every eligible Headache Center patient.

The Headache Center is also adding new-patient visits at Mason, Liberty, Burnet and Crestview Hills. The Crestview Hills site gives Northern Kentucky families their first nearby option for new-patient headache visits.

Research continues alongside clinical care. The Headache Center has at least 10 active studies of acute and preventive treatments. Many focus on medications approved for adults to see whether they’re safe and effective for children and adolescents. Others look at behavioral interventions.

Refer a Patient

The infusion pathway is available to patients who are established with Cincinnati Children’s Neurology. Outside referrals are first seen for a new-patient evaluation to confirm a primary headache diagnosis.

To refer a patient to the Headache Center, call 513-636-4222

For questions about the infusion pathway, contact headache@cchmc.org.

(Published November 2026)

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