What is the minimum number of headache days per month that the American Academy of Neurology (AAN) considers for preventative treatment in a pediatric patient?

Preventive Treatment Threshold for Pediatric Migraine

The American Academy of Neurology (AAN) does not specify an absolute minimum number of headache days per month for initiating preventive treatment in pediatric patients; instead, the decision should be based on functional impairment, treatment response to acute therapies, and shared decision-making with patients and caregivers. 1

Key Considerations for Pediatric Migraine Prevention

General Indications (Adult-Derived, Applied to Pediatrics)

While the AAN pediatric guideline does not establish a specific headache day threshold, the broader migraine prevention literature provides guidance that clinicians commonly apply to pediatric cases:

• Four or more migraine days per month is a commonly cited threshold for considering preventive therapy 2, 3
• Eight or more headache days per month represents another indication for preventive consideration 3
• Two or more migraine days with significant disability despite appropriate acute treatment warrants preventive therapy 2

Critical Pediatric-Specific Factors

The AAN pediatric guideline emphasizes that the decision to initiate preventive therapy should prioritize:

• Functional impairment and disability rather than an arbitrary headache frequency cutoff 1
• Inadequate response to acute treatments as a key trigger for considering prevention 1
• Assessment and management of comorbid disorders associated with headache persistence 1
• Lifestyle and behavioral factors that influence headache frequency should be counseled first 1

Evidence Limitations in Pediatric Population

A critical caveat: The majority of randomized controlled trials studying preventive medications for pediatric migraine fail to demonstrate superiority to placebo. 1 This fundamentally changes the risk-benefit calculation compared to adults:

• Propranolol is possibly effective (children are possibly more likely to achieve ≥50% reduction in headache frequency) 1
• Topiramate and cinnarizine are probably effective (probably more likely to decrease headache frequency) 1
• Amitriptyline plus cognitive behavioral therapy is more effective than amitriptyline plus headache education alone 1
• Insufficient evidence exists for divalproex, onabotulinumtoxinA, amitriptyline alone, nimodipine, or flunarizine 1

Shared Decision-Making Requirement

Clinicians must engage in shared decision-making with patients and caregivers regarding preventive treatments, including explicit discussion of the limitations in evidence supporting pharmacologic treatments in pediatrics. 1 This is particularly important given the high placebo response rates in pediatric trials.

Medication Overuse Consideration

Before initiating preventive therapy, assess for medication overuse headache:

• Triptans, ergots, combination analgesics: ≥10 days per month for ≥3 months 4
• Simple analgesics: ≥15 days per month for ≥3 months 4
• Medication overuse can worsen underlying migraine and reduce effectiveness of preventive treatments 5