What are the diagnosis and treatment approaches for migraines in pediatric patients?

Pediatric Migraine: Diagnosis and Treatment

Diagnosis

Pediatric migraine diagnosis relies primarily on clinical history using modified ICHD criteria, requiring at least 5 attacks lasting 2-72 hours (shorter than adults), with at least 2 of the following: bilateral or unilateral location, pulsating quality, moderate-to-severe intensity, or aggravation by routine physical activity. 1, 2

Key Clinical Features That Differ from Adults

• Attacks are typically shorter in duration (2-72 hours versus 4-72 hours in adults) 1
• Headache is more often bilateral rather than unilateral 1
• Pulsating quality is less common than in adults 1
• Gastrointestinal symptoms (nausea, vomiting) are prominently featured and may dominate the presentation 1
• Onset typically occurs at or around puberty, with prevalence increasing through adolescence 1

Essential History Components

• Age of onset, duration of episodes, frequency, pain characteristics, aggravating/relieving factors, and accompanying symptoms are all critical 2
• Family history of migraine is crucial as migraine has strong genetic components and is frequently positive in pediatric patients 2
• Parents often provide more reliable descriptions of symptoms and lifestyle factors than young children 1

When to Suspect Migraine

• Recurrent headache of moderate-to-severe intensity 1
• Visual aura symptoms (fortification spectra in >90% of those with aura) 1
• Positive family history of migraine 1
• Symptom onset at or around puberty 1

Neuroimaging Indications

Neuroimaging is NOT indicated for children with normal neurological examination and no red flags, as diagnostic yield is less than 1% for clinically significant findings. 2

Use neuroimaging only when secondary headache disorder is suspected, including: 1

• Recent onset of severe headache
• Change in headache type
• Focal neurological features
• Seizures
• Abnormal neurological examination

When neuroimaging is indicated, MRI without contrast is preferred over CT for non-emergent evaluation, with higher sensitivity for tumors, stroke, and parenchymal abnormalities 2

Acute Treatment

Ibuprofen at weight-appropriate dosing is the recommended first-line medication for acute pediatric migraine. 1, 2

Treatment Algorithm

First-line:

• Bed rest alone may suffice for children with short-duration attacks 1
• Ibuprofen at appropriate dose for body weight when medication is needed 1, 2

Second-line (for adolescents aged 12-17 years):

• Nasal spray formulations of sumatriptan or zolmitriptan are most effective among triptans 1
• Multiple NSAIDs and triptans have FDA approval for this age group 1
• Sumatriptan/naproxen combination, rizatriptan, or almotriptan are additional options 2

Important Caveats

The evidence base for medication therapy in children is confounded by high placebo response in clinical trials, resulting in low apparent therapeutic gain 1

This high placebo response likely explains why benefit of triptans has not been demonstrated in younger children (under age 12) 1

Domperidone can be used for nausea in adolescents aged 12-17 years, though oral administration is unlikely to prevent vomiting 1

Preventive Treatment

Preventive therapy is indicated in patients adversely affected on ≥2 days per month despite optimized acute treatment. 1

Medication Options

In practice, propranolol, amitriptyline, and topiramate are used for preventive treatment, although their effectiveness in children and adolescents has not been proven in clinical trials due to high placebo response 1

Specific recommendations:

• Propranolol (80-160 mg daily) is specifically recommended for pediatric migraine prevention and is appropriate for patients with comorbid hypertension or anxiety 3
• Amitriptyline combined with cognitive-behavioral therapy may be effective 3, 2
• Topiramate is another option, though teratogenic effects must be discussed with adolescent females of childbearing potential 3

Treatment Evaluation

Use headache calendars to track attack frequency, severity, and disability 1, 2

Define treatment success as ≥50% reduction in attack frequency 3

Evaluate treatment effectiveness at 2-3 months, as clinical benefits take this long to manifest 3

When outcomes are suboptimal, review diagnosis, treatment strategy, dosing, and adherence before declaring treatment failure 1, 2

Critical Management Principles

Active involvement from family members and teachers is necessary for clinical management in children and young adolescents, requiring education of both 1

Patients and families must be educated on lifestyle factors, migraine triggers, and avoiding overuse of acute medication to prevent medication overuse headache 2

If acute medication provides insufficient pain relief, referral to specialist care is indicated 1

Discourage medication overuse and recognize established medication overuse to prevent medication overuse headache (MOH) 1

Specialist referral is indicated for patients with chronic migraine 1