What is the treatment for pediatric migraines?

Treatment of Pediatric Migraines

First-line treatment for pediatric migraines includes ibuprofen (7.5-10 mg/kg) and acetaminophen (15 mg/kg) for acute attacks, with triptans (such as sumatriptan nasal spray) for moderate to severe headaches when NSAIDs fail. 1

Acute Treatment Algorithm

1. First-line medications:

   • Ibuprofen 7.5-10 mg/kg per dose
   • Acetaminophen 15 mg/kg per dose
   • Administer at earliest onset of migraine symptoms 1, 2

2. Second-line medications (for moderate-severe attacks or when NSAIDs fail):

   • Sumatriptan nasal spray (for adolescents)
     • Note: Oral sumatriptan is not FDA-approved for pediatric use 3
     • Caution: Avoid in hemiplegic migraine due to theoretical vasoconstriction risk 1

3. Route considerations:

   • Consider non-oral routes (nasal spray) when nausea/vomiting present 1
   • Avoid opioids and butalbital-containing medications due to dependency risk and rebound headaches 1

Preventive Treatment

Initiate preventive therapy when:

• Frequent migraines (typically >4 per month)
• Significant disability despite acute treatment
• Contraindications to acute therapies

First-line preventive options:

• Propranolol (1-4 mg/kg/day)
• Amitriptyline (10-100 mg at night)
• Topiramate (50-100 mg daily) 1

Second-line preventive option:

• Flunarizine (5-10 mg oral once daily) - particularly for hemiplegic migraine 1, 2

Supplement:

• Oral magnesium (weak recommendation) 1

Non-Pharmacological Management

Essential components of treatment plan:

• Regular sleep schedule
• Regular meal times
• Adequate hydration
• Identification and avoidance of migraine triggers
• Stress management techniques 1
• Headache diary to track frequency, triggers, and treatment response 1

Biobehavioral approaches:

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

Monitoring and Follow-up

• Evaluate treatment response within 2-3 months after initiation or change in treatment 1
• Monitor for medication side effects, particularly with:
  • Topiramate (cognitive slowing, weight loss, paresthesias)
  • Amitriptyline (sedation, weight gain, dry mouth) 1
• Set realistic expectations: Complete elimination of headaches is unlikely; goal is reducing frequency, severity, and disability 1

Special Considerations

1. Adolescent females:

   • Discuss teratogenic effects of topiramate and valproate
   • Recommend effective birth control if using these medications
   • Consider folate supplementation 1

2. Safety concerns in pediatric population:

   • Sumatriptan is not FDA-approved for children under 18 years
   • Serious adverse reactions have been reported in pediatric patients including stroke, visual loss, and death
   • A myocardial infarction has been reported in a 14-year-old male following oral sumatriptan use 3

3. Hemiplegic migraine:

   • Consider genetic testing for CACNA1A, ATP1A2, and SCN1A mutations, especially with additional symptoms like ataxia or epilepsy
   • Be aware of increased stroke risk in familial hemiplegic migraine 1

Common Pitfalls to Avoid

• Delaying treatment of acute attacks (early intervention is more effective)
• Using opioids or butalbital-containing medications which can lead to medication overuse headache
• Failing to address lifestyle factors and triggers
• Setting unrealistic expectations for complete headache elimination
• Using triptans in hemiplegic migraine due to theoretical vasoconstriction risk
• Inadequate follow-up to assess treatment efficacy

Despite limited FDA-approved options for pediatric migraine, evidence supports a structured approach using both pharmacological and non-pharmacological strategies to effectively manage this debilitating condition.