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 – ibuprofen or acetaminophen

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ACUTE
|
acute episode
1st line – 

ibuprofen or acetaminophen

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] [ Cochrane Clinical Answers logo ] ​​​​ 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.

Analgesia should be taken as soon as possible after the onset of the acute attack. The sooner the drug is administered after the attack is recognized, the more likely it is to relieve symptoms.[26]

The child should be removed from any environmental triggers that may be contributing to the migraine attack. Sleep is very good at terminating an attack and should be encouraged whenever possible.

Primary options

ibuprofen: 10 mg/kg orally as a single dose

Secondary options

acetaminophen: 15 mg/kg orally as a single dose

Consider – antiemetic

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ACUTE
|
acute episode
Consider – 

antiemetic

Treatment recommended for SOME patients in selected patient group

An antiemetic (e.g., metoclopramide, ondansetron) can be used in children who have nausea and/or vomiting as part of their presentation.[26]​ Early administration in attacks is recommended.

Primary options

metoclopramide: children ≥2 years of age: 0.2 mg/kg intravenously as a single dose, maximum 10 mg/dose

OR

ondansetron: 8-15 kg body weight: 2 mg orally as a single dose, or 0.15 mg/kg intravenously as a single dose; 16-30 kg body weight: 4 mg orally as a single dose, or 0.15 mg/kg intravenously as a single dose; ≥31 kg body weight: 8 mg orally as a single dose, or 0.15 mg/kg intravenously as a single dose, maximum 8 mg/dose (oral) or 4 mg/dose (intravenous)

2nd line – triptan

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ACUTE
|
acute episode
2nd line – 

triptan

Triptans (5-HT1 receptor agonists) are indicated for patients who do not experience significant relief with nonprescription analgesics.[26][32]​​ [ Cochrane Clinical Answers logo ] [ Cochrane Clinical Answers logo ]

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).

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.

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 a triptan can be advised to combine the triptan with a nonsteroidal anti-inflammatory drug (NSAID), which has shown better results than when either drug is taken independently in adult patients.[35]​ A combination formulation of sumatriptan/naproxen is approved for use in patients ages ≥12 years.

Primary options

rizatriptan: children ≥6 years of age and <40 kg body weight: 5 mg orally as a single dose; children ≥6 years of age and ≥40 kg body weight: 10 mg orally as a single dose

OR

almotriptan: children ≥12 years of age: 6.25 to 12.5 mg orally as a single dose, may repeat after at least 2 hours, maximum 25 mg/day

OR

zolmitriptan nasal: children ≥12 years of age: 2.5 to 5 mg intranasally as a single dose, may repeat after at least 2 hours, maximum 10 mg/day

Secondary options

sumatriptan/naproxen sodium: children ≥12 years of age: 85 mg (sumatriptan)/500 mg (naproxen) as a single dose

Consider – antiemetic

Back
ACUTE
|
acute episode
Consider – 

antiemetic

Treatment recommended for SOME patients in selected patient group

An antiemetic (e.g., metoclopramide, ondansetron) can be used in children who have nausea and/or vomiting as part of their presentation.[26]​ Early administration in attacks is recommended.

Primary options

metoclopramide: children ≥2 years of age: 0.2 mg/kg intravenously as a single dose, maximum 10 mg/dose

OR

ondansetron: 8-15 kg body weight: 2 mg orally as a single dose, or 0.15 mg/kg intravenously as a single dose; 16-30 kg body weight: 4 mg orally as a single dose, or 0.15 mg/kg intravenously as a single dose; ≥31 kg body weight: 8 mg orally as a single dose, or 0.15 mg/kg intravenously as a single dose, maximum 8 mg/dose (oral) or 4 mg/dose (intravenous)

ONGOING

≥1 significant migraine per week

1st line – lifestyle modifications + patient and family education

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ONGOING
|
≥1 significant migraine per week
1st line – 

lifestyle modifications + patient and family education

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 explore the factors listed below. It is unclear which of these lifestyle factors are the most significant.[5][36]​​

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]

Patient and parent education about migraine is essential and should be detailed and holistic.

1st line – topiramate or amitriptyline (preventive)

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ONGOING
|
≥1 significant migraine per week
1st line – 

topiramate or amitriptyline (preventive)

Pharmacotherapy is a first-line option in patients who have a preference for drug treatment.

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. Evidence for the efficacy of preventive treatments in pediatric migraine 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. 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.

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.

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.

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.

Primary options

topiramate: children 6-11 years of age: consult specialist for guidance on dose; children ≥12 years of age: 25 mg orally once daily at bedtime initially for 1 week, increase gradually according to response, maximum 200 mg/day given in 2 divided doses

OR

amitriptyline: children ≥2 years of age: 0.1 to 0.25 mg/kg orally once daily at bedtime initially, increase gradually according to response, maximum 2 mg/kg/day or 75 mg/day given in 2 divided doses

Plus – lifestyle modifications + patient and family education

Back
ONGOING
|
≥1 significant migraine per week
Plus – 

lifestyle modifications + patient and family education

Treatment recommended for ALL patients in selected patient group

Nonpharmacologic interventions focused on lifestyle changes and trigger prevention are employed concomitantly to maximize the response rate and long-term improvement in headache frequency.

An 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.

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 a small dose of 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]

2nd line – propranolol (preventive)

Back
ONGOING
|
≥1 significant migraine per week
2nd line – 

propranolol (preventive)

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. Evidence for the efficacy of preventive treatments in pediatric migraine 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. 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.

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.

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.

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.

Primary options

propranolol hydrochloride: <35 kg body weight: 10 mg orally once daily initially, increase gradually according to response, maximum 60 mg/day given in 3 divided doses; ≥35 kg body weight: 20-40 mg orally three times daily

Plus – lifestyle modifications + patient and family education

Back
ONGOING
|
≥1 significant migraine per week
Plus – 

lifestyle modifications + patient and family education

Treatment recommended for ALL patients in selected patient group

Nonpharmacologic interventions focused on lifestyle changes and trigger prevention are employed concomitantly to maximize the response rate and long-term improvement in headache frequency.

An 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.

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 a small dose of 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]

3rd line – cyproheptadine (preventive)

Back
ONGOING
|
≥1 significant migraine per week
3rd line – 

cyproheptadine (preventive)

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. Evidence for the efficacy of preventive treatments in pediatric migraine 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. 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.

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]

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.

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.

Primary options

cyproheptadine: consult specialist for guidance on dose

Plus – lifestyle modifications + patient and family education

Back
ONGOING
|
≥1 significant migraine per week
Plus – 

lifestyle modifications + patient and family education

Treatment recommended for ALL patients in selected patient group

Nonpharmacologic interventions focused on lifestyle changes and trigger prevention are employed concomitantly to maximize the response rate and long-term improvement in headache frequency.

An 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.

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 a small dose of 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]

4th line – referral to pediatric neurologist

Back
ONGOING
|
≥1 significant migraine per week
4th line – 

referral to pediatric neurologist

Use of other preventive drugs may be initiated and supervised by a specialist in pediatric neurology. These may include valproic acid, flunarizine, gabapentin, nimodipine, and verapamil. The adverse effect profile of these drugs often dictates their use. These other drugs have been used for migraine prophylaxis but lack evidence of efficacy in children.

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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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