What is the recommended treatment for an acute attack of migraine in children?

Treatment of Acute Migraine Attacks in Children

For acute migraine attacks in children, ibuprofen is the first-line treatment, while adolescents may also benefit from triptans such as sumatriptan nasal spray. 1

First-Line Treatment Options

• Ibuprofen (10 mg/kg) is recommended as the first-line medication for treating pain in both children and adolescents with acute migraine attacks 1, 2
• Acetaminophen (15 mg/kg) is an alternative first-line option, though it may be less effective than ibuprofen 2
• Treatment should be administered early in the migraine attack for maximum effectiveness 1
• For mild attacks in young children, bed rest alone might be sufficient in some cases 1

Second-Line Treatment Options for Adolescents

• For adolescents with moderate to severe attacks or those who don't respond to NSAIDs, consider the following options:
  • Sumatriptan/naproxen oral combination 1
  • Zolmitriptan nasal spray 1
  • Sumatriptan nasal spray 1, 2
  • Rizatriptan orally disintegrating tablets (ODT) 1
  • Almotriptan oral 1

Special Clinical Situations

• For rapidly escalating headache pain, consider non-oral triptan formulations (nasal sprays) 1
• For attacks with significant nausea or vomiting:
  • Use non-oral triptan formulations 1
  • Add an antiemetic medication 1
  • For adolescents aged 12-17 years, domperidone can be used for nausea 1

Treatment Failure Management

• If one triptan is ineffective, try another triptan or a NSAID-triptan combination 1
• For severe, refractory attacks, dihydroergotamine mesylate may be considered (20-40 μg/kg orally or maximum 1 mg/day intravenously), though evidence is limited 2

Important Considerations and Cautions

• Counsel patients and families to treat migraine attacks early for best results 1
• Advise on lifestyle factors and migraine triggers that should be avoided 1
• Warn about medication overuse, which can occur with frequent use of acute medications (≥15 days/month with NSAIDs or ≥10 days/month with triptans) 3, 4
• Avoid opioids and barbiturates due to questionable efficacy, adverse effects, and risk of dependency 3, 5
• The evidence base for medication therapy in children is complicated by high placebo response rates in clinical trials 1
• Nasal spray formulations of triptans appear to be most effective in adolescents 1

When to Consider Preventive Treatment

• Consider preventive treatments in children and adolescents with:
  • Frequent headaches 1
  • Disabling headaches 1
  • Medication overuse 1
• Discuss with patients and families that in many trials, placebo was as effective as the studied preventive medications 1
• Options for prevention include amitriptyline (especially when combined with cognitive behavioral therapy), topiramate, and propranolol 1, 6

By following this algorithmic approach to treating acute migraine attacks in children, clinicians can help reduce symptoms, disability, and improve quality of life for these young patients.