What is the appropriate dosage of zolmitriptan (pediatric dose) for children (peds) suffering from migraines?

Zolmitriptan Dosing for Pediatric Migraine

For adolescents aged 12-17 years with acute migraine, zolmitriptan nasal spray 5 mg is the recommended dose, providing rapid and effective headache relief with a favorable safety profile. 1, 2, 3

First-Line Treatment Approach

• Start with ibuprofen 10 mg/kg as first-line acute treatment for all pediatric migraine patients, administered at the earliest onset of headache. 1, 2, 4, 5

• For mild attacks in younger children, bed rest alone may suffice before initiating pharmacotherapy. 1, 2, 5

When to Use Zolmitriptan in Adolescents

Zolmitriptan should be considered when:

• The patient is ≥12 years old AND
• NSAIDs (ibuprofen) have failed to provide adequate relief OR
• The migraine presents with moderate to severe intensity OR
• Rapid escalation of headache pain occurs OR
• Significant nausea/vomiting is present 1, 2, 4

Specific Zolmitriptan Dosing

Nasal spray formulation (preferred):

• 5 mg intranasal is the FDA-approved and evidence-based dose for adolescents 12-17 years. 1, 2, 4, 3
• The 2.5 mg nasal spray dose is also available but 5 mg demonstrates superior efficacy. 3
• Nasal spray provides faster onset of action, with significant headache response as early as 15 minutes post-administration. 3

Oral formulation:

• 2.5 mg oral tablet can be used, though nasal spray is preferred for faster absorption and when nausea/vomiting is present. 1, 6
• A second dose may be administered 2 hours after the first dose if headache persists or recurs, but no later than 24 hours after initial dose. 7

Critical Age Restriction

• Triptans, including zolmitriptan, have NOT been proven effective in children under 12 years due to high placebo response rates in clinical trials and should not be used as first-line therapy in this age group. 1, 5

Route Selection Algorithm

Choose nasal spray over oral formulation when:

• Nausea or vomiting is a prominent early symptom 1, 2
• Headache pain spikes rapidly 1, 2
• Faster onset of action is desired 3
• Patient has difficulty swallowing tablets 3

If Zolmitriptan Fails

• Try a different triptan (sumatriptan nasal spray, rizatriptan ODT) or an NSAID-triptan combination (sumatriptan/naproxen oral), as individual response varies between triptans. 1, 2

Safety Profile

• Zolmitriptan nasal spray 5 mg is generally well tolerated in adolescents with no serious adverse events reported in pediatric trials. 3
• Adverse events occur in approximately 22% of treated attacks, are typically mild to moderate in intensity, and transient. 7
• Nasopharyngeal adverse events (taste disturbance, nasal discomfort) occur in 5.5% of attacks with nasal spray but are generally mild. 7

Common Pitfalls to Avoid

• Do not delay treatment - early administration is crucial for efficacy. 2, 5
• Do not use triptans more than 10 days per month to prevent medication overuse headache. 2, 5
• Do not prescribe triptans to patients with cardiovascular disease, uncontrolled hypertension, or hemiplegic migraine. 1
• Do not assume triptan failure after one attempt - if one triptan is ineffective, try another as response varies between individuals. 1, 2

Adjunctive Treatment

• Add an antiemetic (domperidone for ages 12-17 years) if nausea or vomiting is prominent, though oral administration is unlikely to prevent vomiting. 1, 2

When to Refer to Specialist

• Refer if acute medications provide insufficient pain relief after adequate trials of multiple agents. 2, 5
• Refer if diagnosis is uncertain or symptoms are atypical. 5