From the Guidelines
Pediatric migraine prophylaxis should be considered when a child experiences frequent, severe, or disabling migraines that significantly impact their quality of life, with first-line medications including topiramate, propranolol, and amitriptyline, as recommended by the 2020 JAMA Neurology study 1.
Key Considerations
- The decision to start prophylactic treatment should be based on the frequency, severity, and impact of migraines on the child's quality of life, as well as the presence of medication overuse 1.
- Lifestyle modifications, such as maintaining regular sleep schedules, adequate hydration, regular meals, stress management, and avoiding identified triggers, are essential alongside medication 1.
- A headache diary can be a valuable tool for tracking frequency, severity, triggers, and response to treatment, allowing for adjustments to the treatment plan as needed 1.
Medication Options
- Topiramate: starting at 0.5-1 mg/kg/day, increasing gradually to 2-3 mg/kg/day divided twice daily, with potential side effects including cognitive slowing and paresthesias 1.
- Propranolol: 1-4 mg/kg/day divided into 2-3 doses, with potential side effects including fatigue, and contraindicated in asthma 1.
- Amitriptyline: 0.25-1 mg/kg/day as a single bedtime dose, with potential side effects including sedation and dry mouth 1.
Treatment Approach
- Prophylactic treatment should be initiated at a low dose and gradually increased to minimize side effects, with regular follow-up every 4-6 weeks during dose adjustment to monitor efficacy and side effects 1.
- The goal of treatment is to reduce headache frequency by at least 50%, with ongoing assessment and adjustment of the treatment plan as needed to achieve this goal 1.
From the FDA Drug Label
Migraine: Propranolol hydrochloride extended-release capsules are indicated for the prophylaxis of common migraine headache The options for prophylaxis of migraine headaches include propranolol.
- Propranolol is indicated for the prophylaxis of common migraine headache 2 However, the label does not specify pediatric migraine headaches. The FDA drug label does not answer the question.
From the Research
Prophylaxis Options for Pediatric Migraine Headaches
- Topiramate is a commonly used medication for pediatric migraine prophylaxis, with studies showing its efficacy and safety in children 3, 4, 5, 6.
- The effective dose of topiramate for pediatric migraine prophylaxis is typically less than 2 mg/kg/day, with higher doses associated with increased side effects 3, 4.
- Other medications used for pediatric migraine prophylaxis include:
- Amitriptyline, which was the most commonly prescribed agent in one study, with a positive response rate of 89% 7.
- Cyproheptadine, which was preferred for younger patients, with a positive response rate of 83% 7.
- Propranolol, valproic acid, naproxen, nimodipine, and imipramine, which were also used in some cases 7.
- The choice of prophylactic medication depends on various factors, including the child's age, medical history, and headache characteristics.
- Studies have shown that prophylactic treatment can reduce headache frequency and improve quality of life for children with migraine 3, 4, 5, 6, 7.