What are the recent guidelines for migraine prophylaxis in children?

Current Guidelines for Migraine Prophylaxis in Children

For children and adolescents with frequent or disabling migraines, the recommended preventive medications include amitriptyline combined with cognitive behavioral therapy, topiramate, and propranolol. 1, 2

Indications for Preventive Treatment

• Consider preventive treatments in children and adolescents who experience:
  • Frequent headaches (typically defined as ≥2 migraine attacks per month) 2
  • Disabling headaches that significantly impact quality of life or school performance 2, 1
  • Medication overuse headaches (using acute medication more than twice a week) 2

First-Line Preventive Medications

• Propranolol: Recommended at 80-160 mg once daily for migraine prophylaxis 3

  • Dosage may be increased gradually to achieve optimal migraine prophylaxis
  • Usual effective dose range is 160-240 mg once daily 3
  • If satisfactory response is not obtained within 4-6 weeks after reaching maximal dose, therapy should be discontinued 3

• Topiramate: Effective for pediatric migraine prophylaxis 2, 1

  • FDA-approved for adolescent migraine prevention 4
  • Effective dose range: 1-3 mg/kg/day or 50-100 mg/day 5, 6
  • Low-dose topiramate (<2 mg/kg/day) has shown effectiveness with fewer side effects 5
  • Higher dose (100 mg/day) showed statistically significant reduction in monthly migraine attacks compared to placebo 6

• Amitriptyline combined with cognitive behavioral therapy: More effective than amitriptyline alone 2, 1

  • Typical dose range: 30-150 mg per day 2

Important Clinical Considerations

• Discuss with patients/families that placebo effect is significant in pediatric migraine trials - many preventive medications showed similar efficacy to placebo in clinical trials 2, 1

• When prescribing topiramate or valproate to adolescent females, discuss teratogenic effects and advise on effective birth control methods and folate supplementation 2, 1

• Monitor for common side effects:

  • Propranolol: dizziness, nausea, fatigue, depression, and insomnia 2
  • Topiramate: weight loss, cognitive effects, and paresthesia 5, 4
  • Amitriptyline: sedation, dry mouth, constipation 1

• Medications with insufficient evidence or not recommended include:

  • Divalproex sodium
  • OnabotulinumtoxinA
  • Amitriptyline alone (without CBT)
  • Nimodipine 2, 1

Treatment Algorithm

1. Initial Assessment:

   • Confirm migraine diagnosis and rule out secondary headaches 2
   • Assess frequency, severity, and disability from headaches 1
   • Identify and address lifestyle factors and triggers 2

2. Start with Lifestyle Modifications:

   • Regular sleep schedule
   • Regular meal times
   • Adequate hydration
   • Stress management 1

3. Select Preventive Medication Based on:

   • Patient age and comorbidities
   • Side effect profile
   • Patient/family preference 2, 1

4. Medication Titration and Monitoring:

   • Start with low dose and gradually increase to effective dose 3, 5
   • Allow 4-6 weeks at therapeutic dose to assess efficacy 3
   • Monitor for side effects and adjust dose accordingly 4

5. Evaluate Treatment Response:

   • Assess reduction in headache frequency, severity, and disability 7
   • Consider treatment successful if ≥50% reduction in headache frequency 6
   • If inadequate response after 8-12 weeks at maximum tolerated dose, consider switching to alternative medication 2

Special Considerations

• Topiramate has the strongest evidence for efficacy in pediatric migraine prevention, with FDA approval for adolescents 6, 4

• The combination of amitriptyline and cognitive behavioral therapy shows better outcomes than medication alone 2, 1

• If discontinuing propranolol, gradually reduce dosage over several weeks to avoid rebound effects 3

• Regular follow-up is essential to monitor efficacy, side effects, and need for dose adjustments 1