Effective management of migraine headache in children and adolescents requires a balanced approach with an individually tailored regimen targeted to treat an acute attack at its onset, blended with bio-behavioral measures, and, in about 1/3 of patients, daily preventive medicines. The key first step is to assess the disability imposed by the recurrent headache pattern, the headache “burden.” Once the burden is established decisions can be made toward selecting the most appropriate course of action. All patients will benefit from some basic bio-behavioral suggestions such as regular sleep, exercise, and eating schedule, moderation of caffeine, and identification of triggers. In addition, all patients should have a readily available analgesic to be used at the onset of a migraine attack. A subset of migraineurs will have sufficient headache burden to necessitate use of daily preventative medications. Unfortunately, there is limited controlled data to provide a comprehensive, evidence-based guideline, however, the most rigorously studied agents for acute treatment are ibuprofen, acetaminophen, and “triptan” nasal spray forms of sumatriptan and zolmitriptan; all of these have shown safety and efficacy in controlled trials. For preventive treatment, flunarizine, not available in the U.S., is the only agent that has demonstrated efficacy in placebo controlled trials, but encouraging data is emerging regarding the use of several antiepileptic agents such as topiramate, disodium valproate, and levetiracetam, as well as the antihistamine cyproheptadine and the antidepressant amitriptyline.

Migraine headaches are a common genetically medicated disabling disorder in children and become increasingly more frequent during the adolescent years. Unfortunately, migraine often goes unrecognized or is misattributed to causes such as sinus disease or emotional disorders. Migraine and tension-type headache are the two most common recurring headache patterns seen in children and are distinguished clinically by their characteristics and accompanying features (Table 1). The key distinctions are the intensity and the presence or absence of stereotypical autonomic symptoms; in fact, tension-type headache is characterized by its non-migraine qualities.

Table 1.

Comparison of migraine and tension-type headache*

Comparison of migraine and tension-type headache*
Comparison of migraine and tension-type headache*

The prevalence of migraine headache steadily increases through childhood and the male:female ratio shifts during adolescence (Table 2). The mean age of onset of migraine is 7.2 years for boys and 10.9 years for girls.1 Migraine is classified according to the International Headache Society (ICHD-2) into three principle groups (Table 3):

Table 2.

Prevalence of migraine headache through childhood

Prevalence of migraine headache through childhood
Prevalence of migraine headache through childhood
Table 3.

Classification of migraine headache*

Classification of migraine headache*
Classification of migraine headache*

1) migraine without aura (formerly known as “common” migraine); 2) migraine with aura (formerly known as “classic” migraine); and 3) childhood periodic syndromes that are commonly precursors of migraine.

The first step in management of a child with migraine is to appreciate the family's expectation. Often, their primary reason for coming to the doctor is not to get medicine, but to be reassured that their child does not have a brain tumor or other life threatening problem. Providing this reassurance is the most fundamental first step toward successful management and may be accomplished on clinical grounds alone, or with the prudent use of neurodiagnostic imaging.

Once the diagnosis of migraine is established and appropriate reassurances provided, the goals for long-term migraine management should be determined. These include 1) reduction of headache frequency, severity, duration, and disability; 2) reduction of reliance on poorly-tolerated, ineffective, or unwanted acute pharmacotherapies; 3) improvement in quality of life; 4) avoidance of acute headache medication escalation; 5) education and enablement of patients to manage their disease to enhance personal control of their migraine; and 6) reduction of headache-related distress and psychological symptoms.2 

To achieve these goals, a balanced, flexible and individually tailored treatment regimen must include bio-behavioral strategies and non-pharmacological methods as well as pharmacological measures. Treatment options may be divided into bio-behavioral strategies, acute therapies, and preventive measures.

Developing an individual plan requires an appreciation for the degree of disability imposed by the patient's headache and the headache pattern and frequency. Understanding the negative impact of the headache on the quality of life will guide the decisions regarding the most appropriate therapeutic course.3,4 Headache calendars are invaluable in determining the frequency and duration of headache and to help identify precipitating or provocative phenomena. Knowledge of the disability and pattern will guide the clinical decisions necessary to tailor the treatment to the patient.

Bio-behavioral strategies include: biofeedback, stress management, sleep hygiene, exercise, and dietary modifications (Table 4). The basic recommendations which should be provided to all migraineurs include regulation of sleep, institution of a regular exercise program, moderation or elimination of caffeine, and encouragement to keep adequately hydrated.

Table 4.

Bio-behavioral strategies to prevent pediatric migraine attacks

Bio-behavioral strategies to prevent pediatric migraine attacks
Bio-behavioral strategies to prevent pediatric migraine attacks

The role of diet remains controversial.5 About 7% to 44% of patients will report that a particular food or drink can precipitate a migraine attack.6,7 In children, the principal dietary triggers are cheese, chocolate and citrus fruits. Wholesale dietary elimination of a list of foods is not recommended since such restrictive diets are excessive and set the stage for a battleground at home when parents attempt to enforce a restrictive diet upon an unwilling child, which ultimately produces heightened tensions. A more reasonable approach is to review the list of foods thought to be linked to migraine and invite the patient to keep a headache diary and see if a temporal relationship exists between ingestion of one or more of those foods and the development of headache. If a link is found, prudence dictates avoiding the offending food substance.

Overuse of over-the-counter analgesics (greater than 5 times per week) can be a contributing factor to frequent, even daily, headache patterns. When recognized, patients who are overusing analgesics must be educated to discontinue the practice. Retrospective studies have suggested that this recommendation alone can decrease headache frequency.8,9 

The pharmacological management of pediatric migraine has been subjected to thorough review, and controlled data is, unfortunately, limited; therefore, recommendations are all “off label.”10–12 

Acute treatments represent the mainstay of migraine management (Table 5). Several acute treatment options should be discussed at the initial office visit so that the patient may determine which works most effectively and safely. Confidence in a particular agent adds to the “cognitive control” of the headache, an important step in overcoming pain. Regardless of which acute treatment is ultimately found to be the most reliable, there are several guiding principles regarding the use of acute treatments which must be included as part of the patient's educational process: 1) Take the medicine as soon as possible when the headache begins (within 30 minutes); 2) Take the appropriate dose; 3) Have the medicine available at the location where the patient usually has headaches (e.g., school); and, 4) Avoid analgesic overuse (more than 5 doses per week).

Table 5.

Acute treatment options for pediatric migraine

Acute treatment options for pediatric migraine
Acute treatment options for pediatric migraine

For the acute treatment of migraine, the most rigorously studied agents are ibuprofen, acetaminophen, and the nasal spray forms of sumatriptan and zolmitriptan, all of which have shown safety and efficacy in controlled trials. For children less than 12 years of age, ibuprofen (7.5 to 10 mg/kg/dose) and acetaminophen (15 mg/kg/dose) have demonstrated efficacy and safety for the acute treatment of migraine.13,14 

For adolescents, if ibuprofen and acetaminophen are ineffective, a “triptan” agent may be considered. While none of the “triptans” have yet been approved by the FDA for use in adolescents, multiple studies have demonstrated the safety of their use in children.15 Thus far, only the nasal spray forms of sumatriptan (5 and 20 mg) and zolmitriptan (5 mg) have demonstrated efficacy in adolescents.16–19 Oral preparations of sumatriptan, eletriptan, almotriptan, and zolmitriptan have failed to demonstrate convincing efficacy in placebo controlled trials.20 

A diverse group of medications are used to prevent migraine attacks. Their use, however, should be limited to those patients whose headaches occur with sufficient frequency (at least 3 headaches per month), severity, and functional disability to warrant a daily treatment program. It is also useful to identify the presence of comorbid conditions (e.g., depression, obesity, sleep disorders) which may suggest the relative benefit of one agent over another.

Ideally, daily migraine prevention agents should be used for a finite period of time. The general recommendation is to provide treatment through all or part of the school year, then gradually eliminate daily agents during summer vacation. Another option in younger children is to use a shorter course (e.g., 6 to 8 weeks) followed by a slow wean.

While there is an unfortunate lack of controlled data regarding drug therapies for migraine prophylaxis in children, data is beginning to emerge. The use of the many of these agents is based upon anecdotal information or extrapolated adult experiences where Level I data exists for amitryptyline, disodium valproate, propranolol, and timolol with a growing body of literature regarding topiramate.21,22 For preventive treatment in the population of children and adolescents with frequent, disabling migraine, flunarizine (not available in the U.S.) has been the most rigorously studied agent and has the best efficacy (vs. placebo) data.23,24 Currently, the typical first-line choices for migraine prophylaxis are cyproheptadine, non-steroidal anti-inflammatory agents (NSAIDs), antiepileptic medications (topiramate and disodium valproate) and amitryptyline (Table 6).

Table 6.

Preventive treatment options for pediatric migraine

Preventive treatment options for pediatric migraine
Preventive treatment options for pediatric migraine

The antihistamine cyproheptadine has anti-serotonergic and calcium channel blocker properties. While not subjected to controlled trials, clinical experience has found cyproheptadine to be successful in reducing headache frequency and intensity, and has been used widely in younger children. Side effects may include sedation and increased appetite.25 

Naproxen sodium, an NSAID, has been shown to be effective in adolescent migraine in one small series. Gastrointestinal upset limits its use as a prophylactic medication to 2 months duration or less.26 

Antidepressants have become the mainstay of migraine prophylaxis in adults, however, there are few studies in children. The tricyclic antidepressants amitriptyline, nortriptyline, and desipramine are common pediatric choices. Studies show statistically significant headache reduction using amitriptyline, with minimal side effects (primarily sedation).27 Selective serotonin reuptake inhibitors (SSRI) may also be efficacious, particularly if there is coexistent depression; unfortunately, there are no studies in children. Of note, the mechanism of action of antidepressants for preventing migraine headaches is reported to be separate from their designed antidepressant effect. However, as awareness of the common comorbidity of affective disorders and migraine expands, the antidepressant properties may play a more important role.

Antiepileptic drugs such as topiramate, disodium valproate, levetiracetam, and gabapentin may have expanding roles for pediatric migraine in the future. The current understanding of migraine pathophysiology demonstrates a migrating wave of regional cortical excitation followed by a prolonged period of neuronal depression, which may be altered by antiepileptics. Numerous retrospective studies show a reduction in headache severity with antiepileptic drugs.28–34 Clearly, more prospective studies are needed in children to assess efficacy and tolerability for use in migraine prevention. Beta-blockers, while often viewed as one of the first-line agents in children, have failed to consistently demonstrate effectiveness in randomized, double-blind studies.

Migraine headache is the most common recurring pain syndrome in childhood and adolescence. Stereotyped attacks of frontal or bitemporal pounding, nauseating headache lasting 1 to 48 hours represent the overwhelming proportion of migraines. The treatment philosophy now embraces a balanced approach with both bio-behavioral interventions and pharmacological measures. Fundamental to treatment decisions is the degree of disability produced by the headaches. Virtually all patients will require an agent such as ibuprofen, acetaminophen, or a “triptan” to treat acute attacks. About 1/3 of patients will have migraine headaches with sufficient frequency and severity to justify the temporary use of preventive medicines. A growing body of controlled pediatric data is beginning to emerge regarding the acute and preventive agents, lessening our dependence upon extrapolated adult data.

In the near future, as advances are made in understanding the neurobiology of migraine, new innovations will be found which will translate to improved quality of life for pediatric patients with migraine headaches.

ICHD

International Headache Society

NSAID

non-steroidal anti-inflammatory drugs

OTC

over the counter

SSRI

selective serotonin reuptake inhibitors

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DISCLOSURE M. Brenner has no financial disclosures. D Lewis has received research grant support from: OMN, GSK, Abbott, Merck, Astra-Zeneca, and American Home Products.