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

Treatment Algorithm for Acute Migraine Attacks in Children

Ibuprofen (10 mg/kg) is the first-line medication for treating acute migraine attacks in children and adolescents, and should be administered early in the attack for maximum effectiveness. 1

First-Line Treatment

• Ibuprofen (10 mg/kg) is recommended as the most effective first-line medication for children with acute migraine attacks 1, 2
• Acetaminophen/paracetamol (15 mg/kg) is an alternative first-line option, though slightly less effective than ibuprofen 1, 2, 3
• Treatment should be administered as early as possible during the migraine attack to maximize effectiveness 1
• For mild attacks in young children, bed rest alone might be sufficient in some cases 1

Second-Line Treatment Options

• For adolescents with moderate to severe attacks or those who don't respond to NSAIDs:
  • Sumatriptan nasal spray (5-20 mg) has demonstrated efficacy and is recommended for adolescents 1, 2, 4
  • Zolmitriptan nasal spray is an effective option for adolescents with moderate to severe attacks 1
  • Sumatriptan/naproxen oral combination can be considered for adolescents 1

Management of Special Clinical Situations

• For attacks with significant nausea or vomiting:
  • Use non-oral triptan formulations (nasal sprays) 1
  • Consider domperidone for nausea in adolescents aged 12-17 years 1
• For rapidly escalating headache pain, non-oral triptan formulations (nasal sprays) are preferred 1
• If one triptan is ineffective, try another triptan or a NSAID-triptan combination 1

Important Considerations and Cautions

• Counsel patients and families to treat migraine attacks early for best results 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) 1
• The evidence base for medication therapy in children is complicated by high placebo response rates in clinical trials 1, 5
• Nasal spray formulations of triptans appear to be most effective in adolescents 1, 4
• Avoid opioids and butalbital for treating acute migraine headaches in children, as they can lead to dependency and medication overuse headache 6

When to Consider Preventive Treatment

• Consider preventive treatments in children and adolescents with:
  • Frequent headaches (two or more migraine attacks per month) 1, 7
  • Disabling headaches affecting quality of life 1
  • Medication overuse 1
  • Failure of or contraindications to acute treatments 7
• Preventive medication options include:
  • Propranolol 7, 4, 3
  • Amitriptyline 7, 4
  • Topiramate 4
  • Flunarizine (5 mg/day) - not available in many countries 5, 3

Non-Pharmacological Approaches

• Identify and avoid migraine triggers (flickering or bright lights, strong smells, noise) 4
• Maintain regular meals and sufficient sleep 4
• Consider relaxation techniques, biofeedback, or cognitive behavioral therapy, which can be effective components of migraine management 5, 8, 3