Can flunarizine be used for migraine prophylaxis in children?

Flunarizine for Migraine Prophylaxis in Children

Flunarizine is an effective second-line medication for migraine prophylaxis in children and can be safely used in pediatric populations. 1, 2

Efficacy and Positioning in Treatment Algorithm

• Flunarizine (10 mg/day) is considered a second-line medication for migraine prophylaxis after first-line options (beta blockers, topiramate, and candesartan) have been tried 1
• Clinical trials demonstrate that flunarizine significantly reduces both the frequency and average duration of headache attacks in children 3
• In comparative studies, flunarizine has shown effectiveness comparable to other prophylactic medications used in pediatric migraine, including propranolol, topiramate, and cyproheptadine 2

Dosing in Children

• For children, the recommended starting dose is 5 mg daily 4, 3
• The dose may be increased to 10 mg daily if there is inadequate response after 2-4 weeks of treatment 4
• Clinical improvement is typically observed between 2-4 weeks after initiating treatment 4

Evidence of Effectiveness

• Double-blind, placebo-controlled studies have shown that flunarizine (5 mg/day) significantly reduces both frequency and duration of migraine attacks in children 3
• A systematic review with meta-analysis confirmed that flunarizine is effective for episodic migraine prophylaxis, supporting guideline recommendations 5
• A recent study (2022) demonstrated that flunarizine significantly reduced Pediatric Migraine Disability Assessment Scores (PedMIDAS) in children with migraine 2

Side Effects and Monitoring

• The most common side effects of flunarizine in children include:
  • Daytime sedation/drowsiness 3
  • Weight gain 5, 3
• Less common but important side effects to monitor:
  • Depression (particularly in older patients) 1
  • Extrapyramidal symptoms (more common in elderly patients but should be monitored in all age groups) 1

When to Consider Prophylaxis

• Migraine prophylaxis should be considered in children when:
  • Symptoms cause frequent school absenteeism 2
  • Quality of life is significantly impaired 2
  • There are recurring emergency room visits 2
  • Frequent analgesic use raises concerns about medication overuse headache 2
  • Patients are adversely affected by migraine on ≥2 days per month despite optimized acute treatment 1

Treatment Algorithm for Pediatric Migraine Prophylaxis

1. Start with first-line agents:

   • Beta blockers (propranolol) 1, 6
   • Topiramate (in children >6 years) 6
   • Candesartan (in older children) 1

2. If first-line agents fail or are contraindicated, consider second-line options:

   • Flunarizine 1, 2
   • Amitriptyline (not recommended in children under 6 years) 6, 7

3. For children under 6 years:

   • Non-pharmacological approaches should be prioritized 6
   • If medication is absolutely necessary, propranolol is preferred 6
   • Flunarizine may be considered when other options have failed 4, 3

Practical Considerations

• Treatment duration should typically be at least 3-6 months before evaluating full efficacy 3
• Regular follow-up is essential to monitor for side effects and assess treatment response 2
• Consider discontinuing treatment after a period of stability to determine if prophylaxis is still needed 1
• Avoid medication overuse of acute treatments during prophylactic therapy 1