Initial Approach to Managing Pediatric Migraines
Start with lifestyle counseling and trigger identification, then use ibuprofen (7.5-10 mg/kg) as first-line acute treatment for all children and adolescents with migraine. 1
Step 1: Establish Diagnosis and Educate
- Take a detailed headache history focusing on attack duration (typically 2-72 hours in children, shorter than adults), location (often bilateral in children vs. unilateral in adults), quality (pulsating), intensity (moderate-severe), and associated symptoms (nausea, photophobia, phonophobia) 1
- Provide education on lifestyle factors including maintaining regular sleep schedules, consistent meal timing, adequate hydration, and stress management techniques 1
- Identify and counsel on avoiding specific migraine triggers when self-evident 1
- Critically important: Counsel families to avoid acute medication overuse (>10 days/month) to prevent medication overuse headache 1
Step 2: Acute Treatment Strategy
First-Line: NSAIDs
- Ibuprofen 7.5-10 mg/kg is the primary recommendation for acute treatment in all pediatric patients 1, 2
- Acetaminophen 15 mg/kg is an alternative but has inferior efficacy and should only be used if ibuprofen is not tolerated 2, 3
- Instruct patients to treat early in the attack when symptoms are still mild for optimal effectiveness 1
Second-Line: Triptans (Adolescents)
For adolescents with moderate-to-severe headaches or inadequate response to NSAIDs, consider: 1
- Sumatriptan/naproxen combination oral 1
- Zolmitriptan nasal spray 1
- Sumatriptan nasal spray 1
- Rizatriptan ODT 1
- Almotriptan oral 1
Special Circumstances
- If headache pain escalates rapidly: Use non-oral triptan formulations (nasal spray) 1
- If nausea/vomiting is prominent: Use non-oral triptan or add an antiemetic 1
- If one triptan fails: Try a different triptan or NSAID-triptan combination, as individual response varies 1
Step 3: Consider Preventive Treatment
Indications for preventive therapy: 1
- Frequent headaches (typically ≥4 per month causing disability)
- Disabling headaches despite acute treatment
- Medication overuse pattern developing
Critical Counseling Point
Discuss with families that placebo was as effective as active medication in many pediatric preventive trials, so shared decision-making about whether to use preventive medication is essential 1
Preventive Options (in order of evidence strength)
- Amitriptyline combined with cognitive behavioral therapy 1
- Topiramate - Discuss teratogenic effects with adolescent females; ensure effective contraception and folate supplementation 1
- Propranolol 1
Note: The 2020 AAN guidelines found that divalproex, onabotulinumtoxinA, amitriptyline alone, and nimodipine had insufficient evidence or were no better than placebo in pediatric trials 1
Step 4: Reassess and Adjust
- Use headache calendars to track frequency, severity, and medication use 1
- Evaluate treatment response within 4-8 weeks 1
- If treatment fails, reassess diagnosis, dosing, adherence, and medication overuse before changing therapy 1
Critical Pitfalls to Avoid
- Never allow acute medication use >10 days per month - this is the threshold for medication overuse headache 1
- Do not dismiss triptans after single failure - different triptans have varying individual efficacy 1
- Do not delay acute treatment - early intervention is significantly more effective 1
- Avoid valproate in females of childbearing potential - absolutely contraindicated due to teratogenicity 1
- Recognize that bed rest alone can be sufficient in young children - not all attacks require pharmacotherapy 1
Age-Specific Considerations
Young children (<12 years): 1, 2
- Ibuprofen remains first-line
- Triptans are not FDA-approved (though rizatriptan has approval for ages 6-17 in the US) 4, 5
- Bed rest in a dark, quiet room may be sufficient for mild attacks 1
Adolescents (≥12 years): 1