What are the treatment options for pediatric migraines?

Treatment Options for Pediatric Migraines

For pediatric migraine treatment, ibuprofen (7.5-10 mg/kg) and acetaminophen (15 mg/kg) should be used as first-line acute treatments, with triptans (particularly sumatriptan nasal spray) recommended for moderate to severe headaches or when NSAIDs fail to provide relief. 1

Acute Treatment Algorithm

First-Line Options:

• Ibuprofen (7.5-10 mg/kg): Safe and effective for mild to moderate pain
• Acetaminophen (15 mg/kg): Alternative for patients who cannot tolerate NSAIDs

Second-Line Options (for moderate to severe headaches):

• Sumatriptan nasal spray: FDA-approved for children as young as 6 years
  • 5 mg for younger children
  • 20 mg for adolescents
• Other oral triptans for adolescents:
  • Zolmitriptan nasal
  • Rizatriptan orally disintegrating tablets (ODT)
  • Almotriptan oral
  • Sumatriptan/naproxen combination

Treatment Pearls:

• Treat early in the attack for best results 1
• If one triptan is ineffective, try another or a NSAID-triptan combination 1
• For rapidly escalating headaches, use non-oral triptans (nasal formulations) 1
• For headaches with nausea/vomiting, add an anti-emetic or use non-oral medication 1

Caution: Sumatriptan is not recommended for patients under 18 years according to FDA labeling due to limited safety data, though clinical practice guidelines support its use in adolescents 2

Preventive Treatment

Consider preventive treatment for children with:

• Frequent headaches (>1 per week)
• Disabling headaches affecting quality of life
• Medication overuse headaches 1

First-Line Preventive Options:

• Amitriptyline with cognitive behavioral therapy: Combination therapy shows better efficacy than medication alone 1, 3
• Topiramate: Effective but requires monitoring for side effects 1, 3
• Propranolol: Consider in patients without asthma 1, 3

Second-Line Preventive Options:

• Cyproheptadine: Often used in younger children due to liquid formulation 3
• Flunarizine (5 mg/day): Likely effective based on available data 4

Important Considerations:

• Discuss with patients/families that placebo response is high in pediatric migraine trials 1
• For females of childbearing age, discuss teratogenic effects of topiramate and valproate; recommend effective birth control and folate supplementation 1
• Avoid divalproex, onabotulinumtoxinA, and nimodipine due to insufficient evidence of benefit 1

Non-Pharmacologic Approaches

These should be implemented alongside pharmacologic treatments:

• Lifestyle modifications:
  • Regular sleep schedule
  • Adequate hydration
  • Regular meals and exercise
  • Stress management 3
• Trigger identification and avoidance 1
• Cognitive behavioral therapy 3
• Biofeedback 3
• Magnesium supplementation: Relatively few adverse effects with good evidence for symptom improvement 3

Clinical Pearls and Pitfalls

• The high placebo response in pediatric migraine trials (up to two-thirds of patients) complicates evidence-based treatment 1, 5
• Combination therapy (medication plus behavioral interventions) is often more effective than medication alone 3
• Medication overuse can worsen headache patterns; monitor frequency of acute medication use
• Consider comorbidities when selecting preventive medications (e.g., avoid propranolol in asthmatic patients) 3
• Early intervention with both acute and preventive treatments leads to better outcomes and improved quality of life 6

Remember that approximately two-thirds of pediatric migraine patients improve with standard therapy, but for the remaining third (about 3% of all children), more aggressive and individualized approaches may be necessary to prevent suffering and disability 1.