Approach
Migraine management is usually multifaceted and adapted to the individual patient. It is divided into:
Immediate migraine attack management
Long-term migraine management.
Successful management of a chronic condition such as pediatric migraine encompasses several important aspects.
First, a therapeutic relationship must be established with the patient and parents, built on trust and transparency. Not infrequently, parents, and at times children, are concerned about the possibility of a more serious underlying diagnosis. A careful history and examination, followed by a careful explanation, will ensure parents' and patients' understanding and adherence to the treatment plan while minimizing unnecessary investigations.
Another important aspect of the approach is to set realistic expectations for treatment. While treatment is aimed at decreasing the frequency and severity of attacks, it cannot prevent or optimally treat every single attack. It is important to recognize and communicate the limitations of available treatment. As such, relying solely on medical treatment to improve patients' migraines is often disappointing for both patients and physicians. Patient and parent education about migraine is essential and should be detailed and holistic.
Management of acute migraine attack
When migraine attacks are infrequent, acute management takes priority.
The following principles are important when designing an acute management plan for a migraine attack:
The sooner the rescue drug is administered after the attack is recognized, the more likely it is to relieve symptoms.[26]
Appropriate doses of rescue drugs must be used; underdosing is discouraged.
Removal from the environment causing or contributing to migraine attacks is essential, and it should be expedited.
Sleep is very good at terminating an attack and should be encouraged whenever possible.
Any abortive treatment used multiple times per week over the long term may lead to rebound headaches.
The physician's role is to provide the patient (and parents) with tools and guidelines, and to design a sound, personalized management plan. Patients and parents are encouraged to explore and modify the intervention so as to discover what works best for them. The efficacy of various abortive drugs is far from perfect, even in ideal scenarios. Trialing a specific abortive drug over several attacks helps establish its usefulness. It is not unusual to try a few abortive drugs before finding the one that works best. Exploring their attacks retrospectively the day after will help the patient understand how to improve their reporting of the onset of the attack, pick up on aura or premonitory symptoms, and further refine the intervention.
Choosing an abortive treatment has to take into consideration the child's ability to swallow pills, how frequently vomiting accompanies a migraine attack, and the child's response to previously tried drugs and their formulation, as well as patient and parent preferences.
Nonprescription analgesics
Self-administration of nonprescription analgesics such as ibuprofen (a nonsteroidal anti-inflammatory drug [NSAID]) or acetaminophen is a reasonable first-line approach to managing migraine attacks, despite limited evidence of effectiveness. Ibuprofen is the preferred treatment because there is more evidence for its effectiveness.[26][32][33] [
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In cases where, despite proper dosing, one of these drugs is ineffective, another drug can be tried.[26] Nonprescription analgesics come in various formulations, allowing their use in children whose migraine attacks are often associated with vomiting. Adverse effects are generally mild and often limited to stomach discomfort associated with ibuprofen. Parents and patients need to be cautioned about the risk of severe liver damage with recurrent, multiple daily dosing of acetaminophen.
Nonprescription combination drugs such as those containing aspirin and caffeine are sometimes found to be helpful by patients. Patients and their families need to be aware of the concerns for Reye syndrome when combination drugs containing aspirin are used in children and adolescents, especially those recovering from viral illnesses such as influenza and chickenpox.
Triptans (5-HT1 receptor agonists)
Triptans are indicated for patients who do not experience significant relief with nonprescription analgesics.[26][32] [
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Several triptans are licensed for use in children. In the US, rizatriptan is approved for use in children ages ≥6 years. Other triptans are approved in the US for use in children ages ≥12 years (e.g., almotriptan, zolmitriptan nasal spray). A combination formulation of sumatriptan/naproxen is also approved for use in patients ages ≥12 years.
Not all triptans have been studied in the pediatric population. Symptom response to abortive treatments, including triptans, can take up to 2 hours; intranasal formulations may have a faster onset of action.[26] Patients taking sumatriptan/naproxen or zolmitriptan nasal spray are more likely to be headache-free at 2 hours compared with placebo.[26]
Zolmitriptan and sumatriptan are available as intranasal formulations, offer faster onset of action, and are good choices in patients with frequent vomiting. A poor response to a particular triptan does not preclude a better response to other triptans. If there is an incomplete response to a triptan and/or a headache recurrence within 24 hours, a second dose of triptan can be administered as soon as 2 hours after the initial dose.
There is a risk of rebound headaches with frequent use of abortive drugs, and it is paramount that physicians advocate the judicious use of abortive drugs and educate patients and parents about the risk of medication-overuse headaches. This risk appears to be higher with triptans (as well as opioids).[34]
Triptans are contraindicated in hemiplegic migraine and migraine with brainstem symptoms. Additionally, triptans are contraindicated in patients with ischemic vascular disease, cardiac accessory pathways, or history of stroke.
Patients with unsatisfactory responses to triptans can be advised to combine the triptan with an NSAID, which has shown better results than when either drug is taken independently in adults.[35]
Because nausea and vomiting are often associated with pediatric migraine, and triptans show no significant effect on these symptoms, some physicians advocate the use of antiemetics.[26] It is essential to keep in mind, however, that many children feel much better soon after they vomit. The choice of adding an antiemetic to the child's abortive treatment plan depends on patient and parent preference.
Opioids and barbiturates, alone or in combination with other drugs such as acetaminophen, aspirin, and caffeine, should never be used as the first-line treatment of pediatric migraine. They have little role in pediatric migraine treatment, given their risk of addiction and medication-overuse headaches with frequent and regular use.
Management of recurrent episodes
Lifestyle modification changes
There is at least a subgroup of patients who achieve marked improvement in the frequency and severity of their migraine attacks by lifestyle modification changes. For each individual patient, various aspects are more important than others, and the practitioner is encouraged to probe the factors listed below. It is unclear which of these lifestyle factors are the most significant.[5][36]
It is widely accepted that poor sleep and psychological stress are major aggravating factors for migraine, responsible at least in part for increased frequency and severity as well as the transformation from episodic migraine into chronic migraine.[37] This is especially true for adolescents. Probing these areas and incorporating meaningful lifestyle changes into the treatment plan are needed for medium- and long-term success.
The recommended amount of sleep for children and teenagers is 10 and 9 hours per night, respectively.[38] While occasional afternoon naps are fine, routine napping after school can be detrimental as it tends to shorten the amount of truly restorative sleep that patients have overnight. Waking up late on the weekends and vacations has a similar effect on overnight sleep. A state of chronic fatigue ensues, and with it, a higher propensity to develop a migraine attack and a tendency for headache to become chronic. After a detailed sleep history is obtained, the physician, using elements of sleep hygiene education and cognitive behavioral therapy for insomnia, can design a meaningful, realistic, individualized sleep improvement plan. Sleep initiation can be promoted by administering preventive drugs at bedtime, if using, because many have a more or less sedating effect (cyproheptadine, for example, can be very useful from this point of view) or by adding melatonin. Alternatively, a referral to a pediatric sleep clinic can be employed.
Psychological stress, as it pertains to migraine, arises most often from academic challenges or expectations and social conflict at school or at home.[21] Not infrequently, there are elements of anxiety and depression involved as well. The stress mitigation plans could range from a simple temporary adjustment of the school demands, to an intensive psychologist intervention and the involvement of a pediatric psychiatrist and/or psychologist.
Skipping meals, an overly disorganized lifestyle, poor hydration, lack of exercise, too much caffeine, and too much screen time are other lifestyle factors that may play a role in a patient's migraine frequency and severity.[5]
Preventive pharmacotherapy
Preventive pharmacologic treatment is recommended once headaches occur on average at least once a week, especially if they lead to school absenteeism or affect a child's social life. Nonpharmacologic interventions focused on lifestyle changes and trigger prevention are employed concomitantly to maximize the response rate and long-term improvement in headache frequency.
Several drugs are used for migraine prevention. Although evidence for their efficacy is scarce, their use is based on expert recommendations and evidence derived from pediatric and adult studies.[5] The clinical trials in pediatric migraine are marred by a very high placebo response rate. A careful balance between the efficacy and adverse effects of preventive drugs is required.
Although some patients respond rapidly, a more common scenario is a slow improvement over weeks to months. Patients are encouraged to request a review with their physician if they do not respond in 1 month, at which time an adjustment in dosing or a trial of a different drug is employed.
The duration of treatment varies from one patient to another. It is generally advisable to stop the preventive drug if the migraine headaches are well controlled for a few months, and restart it only if they return.
The majority of patients respond to a single preventive drug, and polypharmacy is rarely needed. The choice of the preventive drug is dictated by each patient's preferences and the adverse effect profile.
Topiramate, an anticonvulsant, is often used to prevent pediatric migraines, and is approved in the US for the prevention of migraines in children ages ≥12 years. Topiramate is probably more likely than placebo to decrease headache frequency.[5] There is, however, insufficient evidence that topiramate decreases headache days by more than 50%, or that it decreases migraine-related disability.[5] Patients and their families must be made aware of the adverse effects, which include weight loss, paresthesia, kidney stones, and mental fogginess, and how to recognize and mitigate them.
Topiramate exposure during pregnancy is associated with child neurodevelopmental disorders and congenital malformations.[39][40]
In some countries, topiramate is contraindicated in females of childbearing age unless the conditions of a pregnancy prevention program are fulfilled to ensure that patients of childbearing potential: are using highly effective contraception; have a pregnancy test to exclude pregnancy before starting topiramate; and are aware of the risks associated with use of the drug.[41][42]
Tricyclic antidepressants (e.g., amitriptyline) are often used for pediatric migraine prevention, although there are limited efficacy data.[5] Amitriptyline combined with cognitive behavioral therapy (CBT) has shown a greater reduction in headache days and migraine-related disability compared with amitriptyline and migraine education.[5][43] Amitriptyline should be used with extreme caution in children with depression due to a possible increased risk of suicidal ideation and behavior.
Propranolol, a beta-blocker, has limited evidence of efficacy, and it should be used carefully in patients with asthma and depression.[5] Athletes (who require epinephrine for performance) may be reluctant to use it.
Cyproheptadine, an antihistamine with serotonin antagonist and anticholinergic effects, is commonly used in children and adolescents with some evidence of efficacy.[44] Weight gain and sleepiness are the main limiting factors.[45]
Cinnarizine has shown some benefits for migraine prevention. The risks of weight gain and extrapyramidal effects appear low.[5][46] However, it is not available in the US.
Other drugs have been used for migraine prophylaxis but lack evidence of efficacy in children. These may include valproic acid, flunarizine, gabapentin, nimodipine, and verapamil. The adverse effect profile of these drugs often dictates their use. Use of these drugs should only be initiated and supervised by a specialist in pediatric neurology.
There is very little evidence available to support the use of pizotifen, but it is prescribed in some countries for migraine prophylaxis. However, the manufacturer has discontinued the drug in some countries for commercial reasons, and it may no longer be available.
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