What are the treatment options for pediatric migraine?

Treatment Options for Pediatric Migraine

For pediatric migraine treatment, ibuprofen is recommended as first-line acute therapy for children and adolescents, with triptans (including sumatriptan/naproxen oral, zolmitriptan nasal, sumatriptan nasal, rizatriptan ODT, or almotriptan oral) considered for adolescents with inadequate response to NSAIDs. 1

Acute Treatment Options

• Ibuprofen (7.5-10.0 mg/kg) and acetaminophen (15 mg/kg) are safe and effective first-line options for symptomatic treatment 2
• For adolescents, consider the following triptans if NSAIDs are ineffective:
  • Sumatriptan/naproxen oral combination
  • Zolmitriptan nasal spray
  • Sumatriptan nasal spray
  • Rizatriptan orally disintegrating tablets (ODT)
  • Almotriptan oral 1
• If one triptan is ineffective, try another triptan or a NSAID-triptan combination 1
• For rapidly escalating headache pain, consider non-oral triptans for faster onset of action 1
• For patients with significant nausea/vomiting, use non-oral triptans or add an anti-emetic medication 1
• Counsel patients to treat acute migraine early in the attack for best results 1

Preventive Treatment Options

Preventive treatments should be considered for children and adolescents with:

• Frequent headaches
• Disabling headaches
• Medication overuse 1

Recommended preventive medications:

• Amitriptyline combined with cognitive behavioral therapy 1
• Topiramate 1, 3
• Propranolol 1, 3
• Flunarizine (5 mg/day) has shown effectiveness in pediatric migraine 2, 3

Medications with insufficient evidence or not recommended:

• Divalproex sodium 1
• OnabotulinumtoxinA 1
• Amitriptyline alone (without CBT) 1
• Nimodipine 1
• Pizotifen and clonidine are likely ineffective 2

Non-Pharmacologic Approaches

While the 2020 JAMA Neurology guidelines focused primarily on pharmacologic treatments, non-pharmacologic approaches are important components of comprehensive migraine management:

• Lifestyle modifications and trigger avoidance:
  • Regular sleep schedule
  • Regular meal times
  • Adequate hydration
  • Stress management 1
• Avoidance of acute medication overuse 1
• Behavioral interventions:
  • Relaxation techniques
  • Biofeedback
  • Cognitive behavioral therapy 2, 4

Important Clinical Considerations

• Approximately two-thirds of pediatric migraine patients improve with standard therapy, but one-third (representing about 3% of all children) may require more aggressive or innovative approaches 1
• When discussing preventive medications with patients and families, acknowledge that placebo was as effective as studied medications in many trials 1
• For females of childbearing potential, discuss teratogenic effects of topiramate and valproate, and advise on effective birth control methods and folate supplementation 1
• The management of pediatric migraine requires an individualized therapeutic approach that considers developmental factors and potential psychiatric comorbidities 2, 5
• Despite FDA approval for some medications like rizatriptan and topiramate in pediatric/adolescent migraine, their recommendations in guidelines may be lukewarm due to study design limitations 1

Treatment Algorithm

1. Start with accurate diagnosis and identification of triggers
2. Begin acute treatment with ibuprofen or acetaminophen
3. For inadequate response in adolescents, add or switch to appropriate triptan
4. Consider preventive therapy if:
   • ≥4 headache days per month
   • Headaches significantly impact quality of life or school attendance
   • Acute medications are ineffective or overused 5, 3
5. Select preventive medication based on comorbidities, side effect profile, and patient characteristics 3
6. Incorporate non-pharmacologic approaches throughout treatment

The high placebo response rate in pediatric migraine trials highlights the importance of a comprehensive approach that includes both pharmacologic and non-pharmacologic interventions 1, 2.