What is the recommended management approach for migraines in children?

Management of Migraine in Children

For pediatric migraine management, 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

1. First-line medications:

   • Ibuprofen 7.5-10 mg/kg per dose 1
   • Acetaminophen 15 mg/kg per dose 1
   • Administer early in the attack for best results 2, 1

2. Second-line options (for adolescents or when NSAIDs fail):

   • Sumatriptan nasal spray
   • Zolmitriptan nasal spray
   • Rizatriptan orally disintegrating tablet (ODT)
   • Almotriptan oral
   • Sumatriptan/naproxen combination 2, 1

3. Special situations:

   • 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 2, 1
   • If one triptan is ineffective: Try another triptan or NSAID-triptan combination 2, 1

Preventive Treatment

Consider preventive therapy when:

• Headaches occur more than once per week
• Headaches are disabling and affect quality of life
• Medication overuse is present 2, 1

Preventive Medication Options:

1. First-line preventives:

   • Amitriptyline combined with cognitive behavioral therapy (CBT) - shows better efficacy than medication alone 2, 1
   • Topiramate - effective but requires monitoring for side effects 2, 1
   • Propranolol - consider in patients without asthma 2, 1, 3

2. Second-line options:

   • Cyproheptadine - often used in younger patients as it comes in liquid form 3
   • Magnesium supplementation - relatively few adverse effects with good evidence for improvement 3

3. Medications to avoid:

   • Divalproex, onabotulinumtoxinA, and nimodipine due to insufficient evidence of benefit 1
   • For females of childbearing age, use topiramate and valproate with caution due to teratogenic effects; recommend effective birth control and folate supplementation 2, 1

Non-Pharmacological Approaches

1. Lifestyle modifications:

   • Regular sleep schedule
   • Regular meal times
   • Adequate hydration
   • Trigger identification and avoidance
   • Limited consumption of caffeine 1, 4

2. Behavioral interventions:

   • Cognitive behavioral therapy
   • Stress management techniques
   • Biofeedback 3

3. Physical activity:

   • Regular exercise to maintain healthy weight 4

Important Clinical Considerations

• Discuss with patients/families that placebo response is high in pediatric migraine trials, which may influence treatment decisions 2, 1
• Approximately two-thirds of pediatric migraine patients improve with standard therapy, but the remaining third may require more aggressive approaches 1
• Ignoring lifestyle issues and comorbidities can make successful treatment nearly impossible 3
• Treat early in the attack for best results 2, 1
• Make a specific headache diagnosis through detailed history before initiating treatment 2

Monitoring and Follow-up

• Monitor for medication overuse headache
• Assess response to acute treatments
• For preventive medications, allow 6-8 weeks to evaluate efficacy
• Monitor for side effects, particularly with topiramate (cognitive effects, weight loss) and amitriptyline (sedation, weight gain)
• Regularly reassess the need for preventive medication

Migraine in children significantly impacts quality of life and school performance, making effective management crucial for reducing disability and improving outcomes 2, 5.