What is the treatment for migraines in children?

Treatment of Migraines in Children

Ibuprofen is the first-line treatment for acute migraine pain in children and adolescents, while preventive treatment should be considered for frequent or disabling headaches with options including amitriptyline combined with cognitive behavioral therapy, topiramate, or propranolol. 1

Acute Treatment Algorithm

First-Line Options

• Ibuprofen (7.5-10 mg/kg) - Most effective first-line medication with strong evidence 1, 2
• Acetaminophen (15 mg/kg) - Alternative if NSAIDs contraindicated 1, 3

For Adolescents with Inadequate Response

• Triptans (FDA-approved options for adolescents):
  • Sumatriptan nasal spray (5-20mg) - Most evidence in adolescents 1, 3
  • Rizatriptan orally disintegrating tablet (ODT) 1
  • Zolmitriptan nasal spray 1
  • Almotriptan oral 1
  • Sumatriptan/naproxen combination 1

Special Situations

• For rapidly escalating pain: Use non-oral triptan formulations (nasal) 1
• For nausea/vomiting: Add anti-emetic or use non-oral triptan 1
• If one triptan fails: Try another triptan or NSAID-triptan combination 1

Preventive Treatment

When to Consider Prevention

• Frequent headaches (more than once weekly) 1, 2
• Disabling headaches affecting quality of life 1
• Medication overuse headache 1

First-Line Preventive Options

1. Amitriptyline + Cognitive Behavioral Therapy - Combined approach shows best evidence 1
2. Topiramate - Effective but requires monitoring 1, 2
3. Propranolol - Good evidence but caution with asthma 1, 2
4. Flunarizine (5 mg/day) - Likely effective but not available in all countries 3, 4
5. Magnesium supplementation - Minimal side effects, good supporting evidence 2

Important Cautions

• Topiramate and valproate: Discuss teratogenic effects with female adolescents; recommend effective birth control and folate supplementation 1
• Propranolol: May worsen underlying asthma 2
• Amitriptyline: Monitor for serotonergic side effects 2

Non-Pharmacological Approaches

Lifestyle Modifications (Evidence Level B) 1

• Identify and avoid migraine triggers
• Regular sleep schedule
• Adequate hydration
• Regular meals
• Regular exercise
• Stress management

Behavioral Interventions

• Cognitive behavioral therapy 1, 2
• Relaxation techniques 3
• Biofeedback 2, 3

Important Clinical Pearls

1. Early treatment is key: Counsel patients to treat migraines early in the attack for better outcomes 1

2. High placebo response: Discuss with families that in many pediatric migraine trials, placebo was as effective as medication, highlighting the importance of expectation and non-pharmacologic approaches 1

3. Medication overuse: Advise against frequent use of acute medications (>2-3 days/week) to prevent medication overuse headache 1

4. Assess disability: Consider using the PedMIDAS scale to evaluate headache-related disability in children 5

5. Comorbidities: Evaluate and address psychiatric comorbidities, which are common in pediatric migraine 3

The treatment of pediatric migraine requires a structured approach starting with ibuprofen for acute attacks and considering preventive options for frequent or disabling headaches. While the evidence base for pediatric migraine treatment is less robust than for adults, the 2020 AAN guidelines provide clear direction for both acute and preventive approaches.