What is the treatment for migraines in children?

Treatment of Migraine in Children

Ibuprofen is the first-line acute treatment for pediatric migraine, with triptans (particularly nasal formulations of sumatriptan or zolmitriptan) reserved for adolescents who fail NSAIDs. 1, 2

Acute Treatment Algorithm

First-Line Therapy

• Ibuprofen at weight-appropriate dosing is the recommended initial acute treatment for all children and adolescents with migraine 1, 2
• Bed rest alone may suffice for younger children with short-duration attacks 2
• Early treatment of acute attacks yields the best results 1

Second-Line Therapy for Adolescents

When NSAIDs provide inadequate relief, consider the following triptans for patients ≥12 years 3, 1:

• Nasal spray formulations (sumatriptan or zolmitriptan) are most effective among triptans for adolescents 2
• Oral options: sumatriptan/naproxen combination, rizatriptan ODT, or almotriptan 3
• If one triptan fails, try another triptan or an NSAID-triptan combination 3, 1

Special Situations

• Rapidly escalating headache pain: Use non-oral triptans 3, 1
• Significant nausea/vomiting: Use non-oral triptans or add an anti-emetic 3, 1
• Combination NSAID/triptan therapy is more effective than either agent alone for moderate to severe headaches 1

Critical Pitfall

Avoid opioids and butalbital entirely - they cause dependency and medication overuse headache 1. Monitor for medication overuse headache when NSAIDs are used ≥15 days/month or triptans ≥10 days/month 1.

Preventive Treatment Algorithm

Indications for Preventive Therapy

Consider preventive treatment when 3, 1, 2:

• Headaches occur on ≥2 days per month despite optimized acute treatment 2
• Frequent or disabling headaches significantly impact quality of life 3, 1
• Medication overuse is present 3

Evidence-Based Preventive Options

The following medications have the strongest evidence 3, 1:

• Amitriptyline combined with cognitive behavioral therapy (most commonly prescribed, 58% usage rate, 89% positive response, 62% reduction in headache frequency) 3, 4
• Topiramate (most effective at reducing attack frequency, though high placebo response in trials) 3, 5
• Propranolol (80-160 mg daily; particularly appropriate for patients with comorbid hypertension or anxiety) 2, 6

Age-Specific Considerations

• Younger children: Cyproheptadine is preferred (available in liquid form, 83% positive response rate, 55% reduction in headache frequency) 4, 6
• Adolescents: Amitriptyline or topiramate are typically first choices 6

Medications to Avoid

Do not use 3, 1:

• Divalproex sodium (especially in females of childbearing potential due to teratogenicity)
• OnabotulinumtoxinA (insufficient evidence in pediatrics)
• Amitriptyline alone without cognitive behavioral therapy
• Nimodipine

Critical Counseling Point

Discuss with patients and families that placebo was as effective as the studied medication in many preventive trials - this helps set realistic expectations and allows informed decision-making about whether to use preventive medication 3.

Teratogenicity Warning

For adolescent females of childbearing potential, counsel about teratogenic effects of topiramate and valproate, advise effective birth control methods, and prescribe folate supplementation 3.

Non-Pharmacologic Interventions

Lifestyle Modifications (Essential for All Patients)

• Regular sleep schedule 1, 2
• Regular meal times and adequate hydration 1, 2
• Stress management and trigger avoidance 1
• Avoid acute medication overuse 1, 2

Behavioral Interventions

• Relaxation techniques and cognitive behavioral therapy are recommended as first-line interventions 1, 6
• Biofeedback training is effective in reducing frequency and severity 6, 7
• Nonpharmacologic treatment alone is more effective in children younger than 6 years (higher complete/partial response rates compared to older children) 8

Adjunctive Measures

• Keep a headache calendar to monitor frequency, severity, and medication use 1
• Magnesium supplementation has good evidence with relatively few adverse effects 6

Management Principles

Family and School Involvement

Active involvement from family members and teachers is necessary - education of both is required for successful clinical management in children and young adolescents 2.

When to Refer to Specialist

Refer when 2:

• Acute medication provides insufficient pain relief
• Chronic migraine is present
• Standard treatments fail

Expected Outcomes

Approximately two-thirds of pediatric migraine patients improve with standard therapy, but one-third may require more aggressive or innovative approaches 3, 1.