What are the recent guidelines for managing migraines in pediatric patients?

Pediatric Migraine Management: Recent Guidelines

For pediatric migraine management, ibuprofen should be used as first-line acute treatment for children and adolescents, with triptans (particularly nasal formulations) considered for adolescents with moderate to severe headaches that don't respond to NSAIDs. 1

Acute Treatment Algorithm

First-Line Options:

• Ibuprofen (7.5-10 mg/kg): Most effective first-line treatment with strong evidence for pain relief in children and adolescents 1, 2
• Acetaminophen (15 mg/kg): Alternative first-line option, though less effective than ibuprofen 2

Second-Line Options (for adolescents):

• Triptans: For moderate-severe headaches or when NSAIDs fail 1
  • Sumatriptan nasal spray: FDA-approved for adolescents in Europe 3
  • Zolmitriptan nasal spray: FDA-approved for adolescents in Europe 3
  • Rizatriptan ODT: FDA-approved for ages 6-17 in US 3
  • Almotriptan oral: FDA-approved for adolescents in US 3
  • Sumatriptan/naproxen combination: Effective in adolescents 3

Important: Triptans are not recommended for children under 18 years according to FDA labeling 4, though some have specific pediatric approvals.

For Migraine with Nausea/Vomiting:

• Use non-oral route of administration (nasal triptans) 1
• Add antiemetic medication 1

Preventive Treatment Considerations

Consider preventive treatment when:

• Frequent or disabling headaches (≥2 attacks/month with ≥3 days disability) 1
• Acute medication use more than twice weekly 1
• Medication overuse headache is present or at risk 1
• Failure of acute treatments 1
• Uncommon migraine conditions (hemiplegic, prolonged aura, migrainous infarction) 1

Preventive Medication Options:

• Amitriptyline + cognitive behavioral therapy: First-line option 1, 5
• Topiramate: Effective option with caution about teratogenic effects 1, 5
• Propranolol: Evidence supports efficacy 1, 5
• Cyproheptadine: Consider for younger children who cannot swallow tablets 6

Non-Pharmacological Approaches

• Lifestyle modifications: Advise on sleep hygiene, regular meals, hydration 1
• Trigger identification and avoidance: Help patients identify personal triggers 1
• Behavioral approaches: Relaxation techniques, biofeedback, cognitive behavioral therapy 5, 7

Important Clinical Pearls

1. Early treatment: Counsel patients to treat migraine attacks early for better efficacy 1

2. Medication overuse: Limit acute medications to no more than twice weekly to prevent medication overuse headache 1

3. Gender differences: Boys may respond better to ibuprofen than girls, who have higher placebo response rates 8

4. Neuroimaging caution: Neuroimaging has limited value in children with typical migraine presentations and should be reserved for those with concerning neurological signs 5

5. Placebo effect: Discuss with families that placebo was as effective as studied medications in many trials, emphasizing the importance of comprehensive management 1

6. Teratogenic concerns: For adolescent females on topiramate or valproate, discuss teratogenic risks and recommend effective birth control plus folate supplementation 1

7. Referral indications: Consider specialist referral for children with frequent/disabling headaches, insufficient pain relief from acute medications, or medication overuse 5

By following these evidence-based guidelines, clinicians can effectively manage pediatric migraine, reducing disability and improving quality of life for these young patients.