What long-acting triptan is recommended for pediatric patients with migraines with aura?

Triptans Are Generally Not Recommended for Pediatric Migraine with Aura

Triptans should be avoided in pediatric patients with migraine with aura due to safety concerns regarding vascular risk, and when acute treatment is necessary, intranasal sumatriptan or oral almotriptan are the only options with any pediatric evidence, though neither is specifically indicated for migraine with aura. 1, 2

Critical Safety Concern: Avoid Triptans in Migraine with Aura

• The American Heart Association explicitly recommends avoiding triptan agents in children with hemiplegic migraine, basilar migraine, known vascular risk factors, or prior cardiac or cerebral ischemia, at least pending availability of more information. 1

• This recommendation stems from the theoretical stroke risk associated with triptan-induced vasoconstriction in patients who may already have compromised cerebral perfusion during aura phases. 1

• Triptans are most probably not efficacious when taken during the aura phase itself, and should only be considered during the headache phase if used at all. 3

Pediatric-Specific Triptan Evidence

First-Line Option (If Triptan Must Be Used):

• Intranasal sumatriptan is the only triptan with positive efficacy data in pediatric patients and is approved in Europe for children older than 12 years. 2

• The American Academy of Neurology's 2004 treatment parameter recommended that nasal sumatriptan be considered for acute treatment in pediatric migraine. 2

• Oral sumatriptan does not show any clinical benefit versus placebo in children and should be avoided. 2

Second-Line Option:

• Almotriptan is the first and only triptan with FDA approval for adolescents (12-17 years) with migraines lasting 4 or more hours. 2

• However, this approval was based on limited data (one large trial and one very small open-label pilot study), and there is no specific evidence for its use in migraine with aura. 2

"Long-Acting" Triptan Consideration

• Among triptans, naratriptan has the longest half-life, but it is NOT recommended for pediatric use due to insufficient efficacy and safety data in this population. 1, 4, 2

• Naratriptan safety and effectiveness in pediatric patients have not been established, and it is not recommended for use in patients younger than 18 years of age. 4

• A controlled clinical trial of naratriptan in 300 adolescents (ages 12-17) showed no statistically significant differences from placebo, with headache response rates of 65% for placebo versus 64-67% for naratriptan groups. 4

• Frovatriptan, another long-acting triptan, has no efficacy data in pediatric patients, which limits its use in this population. 2

Evidence Regarding Aura and Triptan Response

• In pediatric populations, aura does not predict triptan response (contrary to adult data), with 67% of pediatric patients with aura responding to triptans versus 74% without aura (not statistically significant). 5

• However, this does not override the safety concerns about using triptans in children with specific aura subtypes (hemiplegic, basilar). 1

Recommended Clinical Approach

Step 1: First-Line Non-Triptan Treatment

• Start with NSAIDs (ibuprofen or naproxen) as first-line acute treatment for pediatric migraine with aura. 1, 6

• NSAIDs have proven efficacy and avoid the vascular concerns associated with triptans in this population. 1

Step 2: If Triptan Absolutely Required

• Use intranasal sumatriptan (5-20 mg) only during the headache phase, never during aura. 2, 6

• For adolescents 12-17 years, almotriptan 12.5 mg orally may be considered as an alternative. 2

Step 3: Frequency Limitation

• Limit acute medication use to no more than 2 days per week to prevent medication-overuse headache. 6

Step 4: Consider Preventive Therapy

• If attacks occur more than twice weekly, initiate preventive therapy rather than relying on acute treatment. 6

• Options include amitriptyline, sodium valproate, cyproheptadine, or calcium channel antagonists. 1

Critical Pitfalls to Avoid

• Never use triptans during the aura phase - they are ineffective and may theoretically increase vascular risk. 3

• Do not prescribe long-acting triptans (naratriptan, frovatriptan) to pediatric patients - they lack efficacy data and FDA approval in this age group. 4, 2

• Screen for contraindications including hemiplegic migraine, basilar migraine, cardiovascular disease, and uncontrolled hypertension before prescribing any triptan. 1

• Avoid oral sumatriptan in pediatric patients as it shows no benefit over placebo. 2