What is the initial management approach for pediatric migraine?

Initial Management Approach for Pediatric Migraine

The initial management of pediatric migraine should begin with ibuprofen as first-line acute therapy, while counseling patients and families about lifestyle factors, migraine triggers, and the importance of early treatment during an attack. 1, 2

Acute Treatment

• Ibuprofen (7.5-10 mg/kg) is recommended as the first-line medication for pain relief in children and adolescents with migraine due to its efficacy and safety profile 1, 2
• Acetaminophen can be used as an alternative for patients who cannot tolerate NSAIDs, though it has less efficacy 1, 2
• For adolescents with inadequate response to NSAIDs, triptans should be considered as second-line therapy 1, 2:
  • Sumatriptan/naproxen oral combination
  • Zolmitriptan nasal spray
  • Sumatriptan nasal spray
  • Rizatriptan orally disintegrating tablets (ODT)
  • Almotriptan oral
• If one triptan is ineffective, trying another triptan or a NSAID-triptan combination may be beneficial 1, 2
• For rapidly escalating headache pain, consider non-oral triptans 1
• For significant nausea/vomiting, add an anti-emetic or use non-oral medication routes 1, 2
• Treat migraine attacks early for best results 1

Lifestyle Modifications and Trigger Management

• Identify and avoid individual trigger factors that precipitate migraine attacks 1, 2
• Maintain regular sleep schedules and meal times to reduce migraine frequency 2
• Ensure adequate hydration 2
• Manage stress through appropriate techniques 2
• Avoid medication overuse (no more than 10 days of acute medication use per month) to prevent medication overuse headache 1

When to Consider Preventive Treatment

• Preventive treatments should be considered in children and adolescents with 1, 2:
  • Frequent headaches (typically >4 per month)
  • Disabling headaches that significantly impact quality of life
  • Medication overuse headache
  • Inadequate response to acute treatments

Preventive Treatment Options

• First-line preventive medications to consider 1, 2:
  • Amitriptyline combined with cognitive behavioral therapy
  • Topiramate
  • Propranolol
• When discussing preventive medications with patients and families, it's important to 1:
  • Acknowledge that placebo was as effective as studied medications in many trials
  • Discuss the evidence for and side effects of recommended medications
  • For medications with teratogenic effects (topiramate, valproate), discuss contraception and folate supplementation with adolescent females

Practical Approach to Management

• Use headache diaries to track frequency, intensity, and medication use 2
• Implement a multidisciplinary approach including pharmacological and non-pharmacological strategies 2, 3
• Approximately two-thirds of pediatric migraine patients improve with standard therapy, but one-third may require more intensive approaches 1, 2
• Recognize that early intervention can prevent progression to chronic daily headache 4

Common Pitfalls to Avoid

• Delaying treatment of acute attacks (early treatment is more effective) 1
• Overusing acute medications, which can lead to medication overuse headache 1
• Failing to address lifestyle factors and triggers 1, 2
• Not considering preventive therapy when indicated 1
• Using medications with insufficient evidence or not recommended for pediatric migraine (e.g., divalproex sodium, onabotulinumtoxinA, amitriptyline alone, nimodipine) 2