Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

ACUTE

acute episode

1st line – analgesic

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ACUTE
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acute episode
1st line – 

analgesic

The administration of simple analgesics in adequate doses is a reasonable first approach to managing acute paroxysms.[28] Paracetamol or ibuprofen are considered first-line options in children.

If simple analgesics prove ineffective, codeine is a potential next step (and last-resort option) used by some practitioners, although it is contraindicated in children younger than 12 years of age, and is not recommended in adolescents 12 to 18 years of age who are obese or have conditions such as obstructive sleep apnoea or severe lung disease as it may increase the risk of breathing problems.[29] It is generally recommended only for the treatment of acute moderate pain, which cannot be successfully managed with other analgesics, in children 12 years of age and older.[30][31] Strong evidence for benefit is lacking and the risk of adverse effects is high. Sedation and constipation are relatively common adverse effects, and respiratory depression occurs in overdose. It should be used at the lowest effective dose for the shortest period and treatment limited to 3 days.[30][31]

Primary options

paracetamol: 10-15 mg/kg orally every 4-6 hours when required, maximum 75 mg/kg/day

OR

ibuprofen: 5-10 mg/kg orally every 6-8 hours when required, maximum 40 mg/kg/day

Secondary options

codeine phosphate: children ≥12 years of age: consult specialist for guidance on dose

Consider – anti-emetic

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ACUTE
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acute episode
Consider – 

anti-emetic

Additional treatment recommended for SOME patients in selected patient group

An anti-emetic can be used in children who have nausea and/or vomiting as part of their presentation. Early administration in attacks is recommended.

Promethazine and prochlorperazine are contraindicated in children aged <2 years due to the risk of respiratory depression.

Prochlorperazine is also contraindicated in children who weigh <9kg.

Primary options

cyclizine: children ≥6 years of age: 25 mg orally every 6-8 hours when required, maximum 75 mg/day

OR

promethazine: children ≥2 years of age: 0.25 to 1 mg/kg orally/rectally/intramuscularly/intravenously every 4-6 hours when required, maximum 25 mg/dose or 100 mg/day

OR

prochlorperazine: children >2 years of age and body weight 9-13 kg: 2.5 mg orally (immediate-release) once or twice daily when required, maximum 7.5 mg/day; children >2 years of age and body weight 14-17 kg: 2.5 mg orally (immediate-release) two to three times daily when required, maximum 10 mg/day; children >2 years of age and body weight 18-39 kg: 2.5 mg orally (immediate-release) three times daily when required, or 5 mg twice daily when required, maximum 15 mg/day; children >2 years of age and body weight >39 kg: 5 mg orally (immediate-release) three to four times daily when required, maximum 20 mg/day

OR

ondansetron: consult specialist for guidance on dose

2nd line – 5-HT1 agonist (triptan)

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ACUTE
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acute episode
2nd line – 

5-HT1 agonist (triptan)

For children with refractory symptoms, a 5-hydroxytryptamine 1 agonist may be considered. [ Cochrane Clinical Answers logo ] Choice of agent will depend on local licensing regulations. Use as early as possible after attack starts.

Published trials to date (although in small patient populations) seem to endorse the use of intranasal sumatriptan, and it is licensed for use in the UK in children 12 years of age and older.[27] Taste may be a limiting factor for use in many children.

Oral rizatriptan is licensed for use in the US (in children 6 years of age and older) but not in the UK, although the evidence to unequivocally endorse use in the paediatric population is not yet available.[36][37][38]

Oral almotriptan is licensed for use in adolescents (12 years of age and older) in the US but is not available in some other countries. The evidence for clinical benefit is from one double blind, placebo-controlled, parallel-group trial of patients aged 12 to 17 years.[39] The only other published paediatric data are limited to two small open label studies.[40][41] [ Cochrane Clinical Answers logo ]

In one study, intranasal zolmitripan was found to be superior to placebo for providing some relief from migraine symptoms in adolescents, and was well tolerated.[35]

Few data support the use of oral sumatriptan, but it is licensed for use in the UK in children 6 years of age or older, and it may be used off-label in other areas.[13][32][33][34]

Primary options

sumatriptan nasal: children ≥12 years of age: 10 mg in one nostril as a single dose, may repeat in 2 hours, maximum 20 mg/day

Secondary options

rizatriptan: consult specialist for guidance on dose

OR

almotriptan: consult specialist for guidance on dose

OR

zolmitriptan nasal: consult specialist for guidance on dose

Consider – ibuprofen

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ACUTE
|
acute episode
Consider – 

ibuprofen

Additional treatment recommended for SOME patients in selected patient group

For acute attacks, there is some trial evidence to support the use of a combination therapy that includes a triptan and a non-steroidal anti-inflammatory drug.[28][42]

Primary options

ibuprofen: 5-10 mg/kg orally every 6-8 hours when required, maximum 40 mg/kg/day

ONGOING

frequency and severity of attack has an impact on quality of life and school attendance

1st line – prophylaxis with propranolol or pizotifen

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ONGOING
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frequency and severity of attack has an impact on quality of life and school attendance
1st line – 

prophylaxis with propranolol or pizotifen

Propranolol is used as a prophylactic agent, although the evidence from published studies is conflicting.[44] It should not be used in children with asthma, and athletes (who require adrenaline for performance) may be reluctant to use it. Start at lowest dose and increase as required according to response and as adverse effects allow.

Counselling on lifestyle and behavioural factors that affect headache frequency, and assessment and management of comorbidities that may be associated with persistence of headache, should also form part of management.[44]

There is very little evidence available to support the routine use of pizotifen, but it is nevertheless very widely prescribed in countries such as the UK as an attempt at prophylaxis. However, the manufacturer is discontinuing this drug in some countries for commercial reasons, and it may no longer be available.

Primary options

propranolol: 0.5 to 1 mg/kg/day orally given in divided doses every 8 hours

Secondary options

pizotifen: refer to consultant for guidance on dosage

2nd line – prophylaxis with topiramate

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ONGOING
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frequency and severity of attack has an impact on quality of life and school attendance
2nd line – 

prophylaxis with topiramate

Topiramate has been approved in the US for the prevention of migraine headaches in adolescents aged 12 to 17 years.

All agents should be initiated in discussion with or supervised by a paediatric neurologist.

Careful explanation of potential adverse effects, including those that necessitate urgent medical assessment, is also important.

Primary options

topiramate: refer to consultant for guidance on dosage

3rd line – prophylaxis with other anticonvulsants or amitriptyline

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ONGOING
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frequency and severity of attack has an impact on quality of life and school attendance
3rd line – 

prophylaxis with other anticonvulsants or amitriptyline

All agents should be initiated in discussion with or supervised by a paediatric neurologist.

Careful explanation of potential adverse effects, including those that necessitate urgent medical assessment, is also important.

There is a risk of anticholinergic adverse effects (e.g., constipation, urinary hesitancy, blurred vision, tachycardia) with this medicine, and pre-treatment counselling should include discussion about these effects.

Sedation is experienced by some, and it is therefore advisable to start with a once-daily evening dose.

Dose and dose frequency can be increased as required and as tolerated.

In 2018, the European Medicines Agency (EMA) finalised a review of valproate and its analogues, recommending that these medicines are contraindicated for migraine prophylaxis during pregnancy due to the risk of congenital malformations and developmental problems in the infant/child.[46] In the US, valproate and its analogues are contraindicated for migraine prophylaxis in pregnant women. In both Europe and the US, valproate and its analogues must not be used in female patients of child-bearing age unless there is a pregnancy prevention programme in place and certain conditions are met.[46]

Primary options

valproic acid: refer to consultant for guidance on dosage

OR

gabapentin: refer to consultant for guidance on dosage

OR

carbamazepine: refer to consultant for guidance on dosage

OR

amitriptyline: 0.25 to 1 mg/kg/day orally given at bedtime

4th line – prophylaxis with verapamil or indometacin

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ONGOING
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frequency and severity of attack has an impact on quality of life and school attendance
4th line – 

prophylaxis with verapamil or indometacin

The use of these agents for this indication should be supervised by a paediatric neurologist.

Careful explanation of potential adverse effects, including those that necessitate urgent medical assessment, is also important.

Primary options

verapamil: refer to consultant for guidance on dosage

OR

indometacin: refer to consultant for guidance on dosage

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Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

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