What is the recommended treatment for migraines in pediatric patients?

Treatment of Migraine in Pediatrics

For acute treatment, use ibuprofen as first-line therapy in all pediatric patients; in adolescents, escalate to triptans (particularly intranasal sumatriptan or zolmitriptan, or oral rizatriptan) if NSAIDs fail after 2-3 attempts. 1

Acute Treatment Algorithm

First-Line: NSAIDs

• Ibuprofen is the recommended first-line acute treatment for children and adolescents with migraine 1
• Counsel families to administer medication early in the attack, as soon as headache begins, for maximum effectiveness 1
• Limit NSAID use to fewer than 15 days per month to prevent medication-overuse headache 1

Second-Line: Triptans (Adolescents Only)

In adolescents with inadequate response to NSAIDs, the following triptans have evidence for efficacy:

• Sumatriptan nasal spray (preferred non-oral formulation) 1
• Zolmitriptan nasal spray 1
• Rizatriptan orally disintegrating tablet (ODT) 1
• Almotriptan oral 1
• Sumatriptan/naproxen combination oral 1

Important caveat: Oral sumatriptan has NOT demonstrated efficacy in pediatric controlled trials, despite FDA approval 2, 3. The nasal formulations perform better in this population 3

Triptan Selection Strategy

• If one triptan fails, try a different triptan or combine an NSAID with a triptan 1
• For rapidly escalating pain, use non-oral triptan formulations (nasal spray preferred over oral) 1
• For significant nausea/vomiting, use non-oral triptans or add an anti-emetic medication 1
• Limit triptan use to fewer than 10 days per month to prevent medication-overuse headache 1

Critical Safety Consideration

Triptans are NOT recommended for children under 12 years of age 2. The FDA label notes that safety and effectiveness have not been established in pediatric patients, and postmarketing reports document serious adverse events including stroke, visual loss, and even death in the pediatric population 2. One case report documented myocardial infarction in a 14-year-old male after oral sumatriptan 2

Preventive Treatment Algorithm

When to Initiate Prevention

Consider preventive therapy when patients experience:

• Frequent headaches (more than one per week) 4
• Disabling headaches affecting school or daily function 1
• Medication overuse (acute medications used more than 2 days per week) 1

Critical Counseling Point

Before prescribing preventive medications, discuss with families that placebo was as effective as active medication in many pediatric trials 1. This high placebo response rate (often 50-60%) means some patients may improve with lifestyle modifications alone 1

First-Line Preventive Options

The evidence supports three primary options, with choice guided by side effect profile and patient factors:

1. Amitriptyline combined with cognitive behavioral therapy 1

   • Most commonly used in clinical practice 4
   • Side effect profile includes sedation and weight gain 4

2. Topiramate 1

   • FDA-approved for pediatric migraine prevention despite lukewarm guideline recommendation due to high placebo response in parallel-design trials 1
   • Critical warning: Highly teratogenic; counsel adolescent females about mandatory effective contraception and folate supplementation 1

3. Propranolol 1

   • Has demonstrated efficacy in systematic studies 3
   • Contraindication: Avoid in patients with asthma due to potential bronchospasm 4

Alternative Preventive Agents (Weaker Evidence)

• Cyproheptadine: Often used in younger children as it comes in liquid formulation 4
• Valproate/divalproex: Use with extreme caution in females of childbearing age due to significant teratogenicity risk 1, 4

Agents with Insufficient Evidence

The following are commonly used but lack robust pediatric evidence: gabapentin, zonisamide, levetiracetam, verapamil, amlodipine 4

Non-Pharmacologic Management

Lifestyle Modifications (Essential Foundation)

Address these factors in ALL patients before or concurrent with medication:

• Regular sleep schedule with sufficient sleep duration 1, 4
• Adequate hydration throughout the day 1, 4
• Regular meals to avoid hypoglycemia triggers 1, 4
• Regular exercise 4
• Identification and avoidance of specific migraine triggers 1, 3

Behavioral Interventions

• Cognitive behavioral therapy is recommended for most patients and enhances medication efficacy when combined with amitriptyline 1, 4
• Stress management techniques 4
• Biofeedback 4

Nutraceuticals

Magnesium supplementation is recommended as it has relatively few adverse effects and good evidence for migraine improvement 4

Common Pitfalls to Avoid

1. Never prescribe opioids or butalbital-containing compounds for pediatric migraine—these lead to medication-overuse headache, dependency, and do not treat the underlying migraine pathophysiology 1

2. Do not use oral sumatriptan as first-line triptan in adolescents despite FDA approval—nasal formulations have better evidence in this age group 2, 3

3. Do not ignore comorbidities—sleep disorders, mood disorders, and anxiety are common and will sabotage treatment success if unaddressed 4

4. Do not prescribe preventive medications without discussing the high placebo response rate in pediatric trials—families need realistic expectations 1

5. Do not forget contraception counseling when prescribing topiramate or valproate to adolescent females—these are highly teratogenic 1

6. Do not allow acute medication overuse—strictly limit NSAIDs to <15 days/month and triptans to <10 days/month 1