What are the first-line treatment protocols for pediatric headaches?

Pediatric Headache Treatment Protocols

For acute pediatric migraine, ibuprofen (7.5-10 mg/kg) is the first-line treatment, with bed rest alone potentially sufficient for mild cases. 1

First-Line Acute Treatment

• Ibuprofen 7.5-10 mg/kg is the primary acute treatment for pediatric migraine, with proven safety and efficacy 2
• Acetaminophen 15 mg/kg serves as an alternative when ibuprofen is contraindicated or not tolerated 2
• Bed rest alone may suffice for mild attacks in children and adolescents before escalating to pharmacotherapy 1

Second-Line Acute Treatment for Adolescents

• Sumatriptan nasal spray (5-20 mg) is effective for adolescents when NSAIDs fail 2, 3
• Four triptans are now FDA-labeled for adolescents, with rizatriptan labeled for children age 6 and older 3
• Consider triptans including sumatriptan/naproxen oral, zolmitriptan nasal, sumatriptan nasal, rizatriptan ODT, or almotriptan oral for adolescents 4

Emergency Department/Severe Migraine Protocol

• Intravenous ketorolac (0.5 mg/kg, maximum 30 mg) for moderate-severe migraines when oral medications are ineffective or not tolerated 4
• Add antiemetics (metoclopramide or prochlorperazine) for accompanying nausea or vomiting 4
• Ketorolac has rapid onset with approximately 6-hour duration and is unlikely to cause rebound headaches with acute use 4
• Limit ketorolac duration to no more than 5 days 4

Important Contraindications for Ketorolac

• Aspirin/NSAID-induced asthma 4
• Pregnancy 4
• Active peptic ulcer disease 4
• Significant renal impairment 4

Preventive Treatment (When Indicated)

Preventive therapy should be considered for children with ≥2 migraine attacks per month producing disability for ≥3 days per month. 1

First-Line Preventive Options

• Propranolol is suggested for migraine prevention in children 1
• Amitriptyline 10-100 mg oral at night (contraindicated in age <6 years, heart failure, co-administration with MAOIs/SSRIs, glaucoma) 1
• Topiramate 50-100 mg oral daily (contraindicated in nephrolithiasis, pregnancy, lactation, glaucoma) 1

Evidence-Based Preventive Medications

• Flunarizine 5 mg/day is likely effective based on available data 2
• Pizotifen and clonidine are likely ineffective and should be avoided 2
• Insufficient evidence exists for cyproheptadine, divalproex sodium, levetiracetam, gabapentin, or zonisamide 2

Comprehensive Management Strategy

Approximately 60% of pediatric migraine patients improve with a three-pronged approach: 3

1. Lifestyle management counseling addressing sleep, exercise, hydration, caffeine intake, and avoidance of meal skipping 3
2. Optimally dosed acute therapy with NSAIDs and triptans (when age-appropriate) 3
3. Preventive treatment with evidence for efficacy 3

Critical Medication Overuse Prevention

• Limit acute treatment to <10 days per month for triptans 5
• Limit acute treatment to <15 days per month for NSAIDs/acetaminophen 5
• Medication overuse headache is defined as headache occurring ≥15 days per month for ≥3 months due to overuse of acute medication 1
• Preventive therapy should be initiated if medication overuse is suspected or at risk 1

Special Considerations

Headache with Severe or Worsening Features

• Children with severe or worsening headache after mild traumatic brain injury are at moderate risk for intracranial complications 1
• Nonopioid analgesics (ibuprofen, acetaminophen) are recommended; opioids are not generally recommended 1

Chronic Headache Management

• Refer for multidisciplinary evaluation and treatment when headaches become chronic 1
• Consider analgesic overuse as a contributory factor in chronic cases 1
• Biopsychosocial, multidisciplinary approach including both medication management and psychological treatment is essential 6

Vestibular Symptoms

• Refer to vestibular rehabilitation program if persistent vestibulo-oculomotor dysfunction is present 1

Sleep Disturbances

• Provide guidance on proper sleep hygiene methods to facilitate recovery 1
• Refer to sleep disorder specialist if problems persist despite appropriate sleep hygiene 1

Common Pitfalls to Avoid

• Never use opioids or butalbital for pediatric migraine treatment due to dependency risk, rebound headaches, and lack of efficacy 1, 5
• Do not prescribe rescue medications containing opioids or butalbital for home use 5
• Avoid using triptans during the aura phase—they are most effective when taken early when headache is still mild 1
• In children, use reduced ATRA dose (25 mg/m²) instead of standard adult dose to decrease frequency of severe headache and pseudotumor cerebri 1