Treatment Approach for Pediatric Migraines Causing School Absences
For children missing school due to migraines, implement a dual-strategy approach: ibuprofen 10 mg/kg at the earliest sign of headache for acute treatment, combined with preventive therapy (amitriptyline plus cognitive behavioral therapy, topiramate, or propranolol) when migraines occur ≥2 days per month despite optimized acute treatment. 1
Acute Treatment Algorithm
First-Line: NSAIDs for All Ages
- Start with ibuprofen 10 mg/kg at the earliest onset of headache 1, 2
- Counsel patients and families to treat early in the attack, not waiting until pain becomes severe 1
- Acetaminophen 15 mg/kg is an alternative but has lower efficacy; reserve for NSAID-intolerant patients 3
Second-Line: Add Triptans for Adolescents
- For adolescents with inadequate response to ibuprofen, add triptan therapy 1, 2
- Evidence-based options include:
Special Circumstances
- For rapidly escalating pain: Use non-oral triptan formulations (nasal sprays or subcutaneous) 1, 2
- For prominent nausea/vomiting: Use non-oral triptan plus antiemetic 1, 2
- If one triptan fails: Try a different triptan or NSAID-triptan combination 1, 2
Preventive Therapy Indications
Consider preventive treatment when any of the following apply:
- Migraines occur ≥2 days per month with adverse effects despite optimized acute treatment 2
- Frequent or disabling headaches 1
- Medication overuse (NSAIDs ≥15 days/month or triptans ≥10 days/month) 1, 2
Evidence-Based Preventive Options
The American Academy of Neurology recommends discussing these three options with families: 1
- Amitriptyline combined with cognitive behavioral therapy (strongest evidence when combined) 1, 2
- Topiramate (discuss teratogenic risks; require effective birth control and folate supplementation in adolescent females) 1
- Propranolol 1, 2
Critical Counseling Point
Inform families that placebo was as effective as many studied medications in pediatric migraine prevention trials 1, 2. This transparency allows shared decision-making about whether to pursue pharmacologic prevention versus non-pharmacologic approaches alone.
Lifestyle Modifications (Essential for All Patients)
Educate patients and families on these specific interventions: 1
- Regular sleep schedule: Consistent bedtime and wake time, including weekends 2
- Regular meal times: No skipping meals 2
- Adequate hydration: Specific daily water intake goals 2
- Identify and avoid migraine triggers 1
- Stress management techniques 2
Medication Overuse Prevention
Set clear limits from the start of treatment: 1, 2
- NSAIDs: Do not exceed 14 days per month 2
- Triptans: Do not exceed 9 days per month 1, 2
- Exceeding these thresholds causes medication overuse headache, worsening the underlying condition 1, 2
School-Specific Interventions
Since school absence is the primary concern, implement these strategies:
- Educate teachers about migraine and the need for early treatment access 2
- Establish a school action plan allowing the child to take medication at first symptom 1
- Create a quiet, dark space at school for brief rest periods if needed 4
- Consider a 504 plan for accommodations if absences are frequent 4
Common Pitfalls to Avoid
- Do not delay treatment: Waiting until pain is severe reduces medication efficacy 1
- Do not use opioids or butalbital: These increase medication overuse headache risk without superior benefit 5
- Do not treat during aura phase: Triptans work during the headache phase, not during aura 5
- Do not prescribe triptans to patients with cardiovascular disease, uncontrolled hypertension, or hemiplegic migraine 2
When to Refer to Specialist
Refer when: 2
- Acute medication provides insufficient pain relief despite optimization
- Diagnosis is uncertain
- Symptoms are atypical or concerning for secondary headache
- Significant psychiatric comorbidities (anxiety, depression) complicate management 2