Migraine headache in children - Emerging treatments

Calcitonin gene-related peptide (CGRP) antagonists

The advances in our understanding of the role CGRP plays in migraine pathophysiology have led to the development of this new class of drugs. Some of the drugs in this class are monoclonal antibodies (e.g., eptinezumab, erenumab, fremanezumab, galcanezumab), while others are small molecules known as gepants (e.g., atogepant, rimegepant, ubrogepant). While these drugs have shown excellent results in the treatment of migraine in adults, none are approved for use in children as yet. Retrospective studies have reported that CGRP antagonist monoclonal antibodies may benefit a proportion of adolescents with chronic refractory headache disorders, and that adverse effects were similar to those reported in adults.[47][48] Ongoing clinical trials are exploring their usefulness in the pediatric population. Guidance based on expert opinion recommends that CGRP antagonist monoclonal antibodies should be considered primarily for post-pubertal adolescents with relatively frequent migraine (i.e., 8 or more headache days per month) and moderate or severe migraine-related disability. They may also be considered for younger children with severe chronic migraine that is refractory to multiple migraine preventive trials, including nonpharmacologic options. Careful monitoring is required.[49]

Noninvasive neuromodulation

Noninvasive neuromodulation therapies are well tolerated, and there is some evidence of effectiveness for acute treatment of migraine, but further studies are needed.[50][51][52] Several neuromodulation devices are now available on the market. There are limited data on their efficacy in pediatric migraine. Each device uses a different neuromodulation intervention. Cefaly®, a Food and Drug Administration (FDA)-approved device for patients 18 years and older, uses supraorbital nerve stimulation for acute and preventive care. Nerivio® is an FDA-approved device for patients 8 years and older designed for acute treatment of migraine attacks. Its proposed mechanism of action is the activation of descending inhibitory pathways.[53] Savi Duo® uses single-pulse transcranial magnetic stimulation and is FDA-approved for acute and preventive treatment of migraine in patients 12 years and older.[54] GammaCore Sapphire®, a noninvasive vagal nerve stimulator, is FDA-approved for patients 12 years and older for acute and preventive treatment of migraine.[55]

Dihydroergotamine (intranasal)

While intranasal dihydroergotamine has not been studied in pediatric migraine, it is occasionally used in cases refractory to triptans.[56]

Nutraceuticals

Magnesium, vitamin B2, feverfew, butterbur, and melatonin are some of the more common nutraceuticals employed for pediatric migraine prevention or abortion, either alone or in various combinations.[57] The evidence is lacking outside small clinical trials.[58][59][60][61][62]