What is the workup and treatment for pediatric migraines?

Workup and Treatment for Pediatric Migraines

Ibuprofen should be used as first-line acute therapy for pediatric migraines, with triptans considered for adolescents who have inadequate response to NSAIDs. 1

Diagnostic Workup

• A thorough headache history should focus on frequency, duration, intensity, location, associated symptoms (nausea, vomiting, photophobia, phonophobia), and triggers 1, 2
• Assessment should identify potential comorbidities including sleep disorders, anxiety, depression, and stress that may exacerbate migraines 1, 3
• Evaluation of medication overuse is critical as it can lead to chronic migraine 1
• Red flags warranting neuroimaging include abnormal neurological examination, early morning headaches, positional headaches, or headaches that wake the child from sleep 2

Acute Treatment

• Ibuprofen (7.5-10 mg/kg) is the first-line treatment for children and adolescents with migraine 1, 4
• Acetaminophen (15 mg/kg) is an alternative first-line option with good safety profile 1, 4
• For adolescents with inadequate response to NSAIDs, triptans should be considered: 1, 5
  • Sumatriptan/naproxen oral combination
  • Rizatriptan orally disintegrating tablets (ODT)
  • Almotriptan oral
  • Sumatriptan nasal spray (5 and 20 mg) for adolescents with significant nausea/vomiting
• Anti-emetics may be added for patients with significant nausea, though this recommendation is based more on clinical practice than strong evidence 6
• Early treatment of acute migraine attacks yields better outcomes 1
• If one triptan is ineffective, trying another triptan or a NSAID-triptan combination may be beneficial 1

Preventive Treatment

• Preventive therapy should be considered for children with:
  • Frequent migraines (typically >4 per month)
  • Disabling headaches that significantly impact quality of life
  • Medication overuse headaches 1, 3
• Evidence-supported preventive options include:
  • Amitriptyline combined with cognitive behavioral therapy 1
  • Topiramate (though evidence is mixed due to study design limitations) 1, 6
  • Propranolol 1
  • Flunarizine (5 mg/day) 4
• Medications with insufficient evidence or not recommended include:
  • Divalproex sodium
  • OnabotulinumtoxinA
  • Amitriptyline alone
  • Nimodipine 1
• When discussing preventive medications with families, acknowledge the significant placebo effect observed in pediatric migraine trials 5
• For adolescent females, discuss potential teratogenic effects of certain preventive medications 1

Non-Pharmacologic Approaches

• Lifestyle modifications should be implemented for all pediatric migraine patients: 1, 4
  • Regular sleep schedule
  • Regular meal times
  • Adequate hydration
  • Avoidance of identified triggers
• Behavioral interventions with demonstrated efficacy include: 1, 4
  • Relaxation techniques
  • Biofeedback
  • Cognitive behavioral therapy
• Stress management strategies should be incorporated into the treatment plan 1, 4

Treatment Algorithm

1. Begin with accurate diagnosis and identification of triggers 1
2. Start acute treatment with ibuprofen or acetaminophen 1, 4
3. For adolescents with inadequate response, add or switch to appropriate triptan 1, 5
4. Consider preventive therapy if headaches are frequent (>4/month), disabling, or significantly impact quality of life 1, 3
5. Incorporate non-pharmacologic approaches throughout treatment 1, 4

Important Clinical Considerations

• Approximately two-thirds of pediatric migraine patients improve with standard therapy, but one-third may require more aggressive approaches 6
• Despite FDA approval for medications like rizatriptan and topiramate, their recommendations in guidelines may be lukewarm due to study design limitations 6
• The high placebo response rate in pediatric migraine trials (often 50-60%) complicates assessment of true medication efficacy 5
• Pediatric migraine presentation may evolve with age, requiring adjustment of treatment strategies over time 2