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Migraine Meds Guidelines for Children and Adolescents?

   

Unfortunately, Migraine doesn't restrict itself to adults. It's estimated that 11 to 12% of the population has Migraine, which is a genetic neurological disease that produces flare ups usually called "Migraine attacks." Migraine is actually common among children, with the frequency of attacks increasing through adolescence. Fortunately, Migraineurs are often spared those attacks during early childhood. Still, they're more common than we might think. The mean age of onset for boys is 7.2-years-old; for girls, 10.9-years-old. The prevalence is lower among younger children and builds:

  • age three to seven years: 3%
  • age seven to 11 years: 4 to 11%
  • age 11 to 15+: 8 to 23%1

Treating children and adolescents with Migraine disease presents even more challenges than treating adult Migraineurs. The American Academy of Neurology Quality Standards Subcommittee and the Practice Committee of the Child Neurology Society set out to review evidence on pharmacologic treatment of children and adolescents with Migraine disease, analyze that evidence, and establish treatment guidelines.1

The team identified and studied 166 articles. The studies on which the article reported reviewed several medications for both acute and preventive therapies:

For acute treatment of Migraine attacks:

  • Sumatriptan (Imitrex® / Imigran®) nasal spray and ibuprofen are effective and are well tolerated versus placebo.
  • Acetaminophen (Tylenol®) is probably effective and is well tolerated versus placebo.
  • Rizatriptan (Maxalt®) and zolmitriptan (Zomig®) were safe and well tolerated but were not superior to placebo.

For daily preventive therapy:

  • Flunarizine (Sibelium®) is probably effective. (Flunarizine is not available in the United States.)
  • The data concerning cyproheptadine (Periactin®), amitriptyline (Elavil®), divalproex sodium (Depakote®, topiramate (Topamax®), and levetiracetam (Keppra®) were insufficient.
  • Conflicting data were found concerning propranolol (Inderal®) and trazodone (Desyrel®).
  • Pizotifen, nimodipine, and clonidine did not show efficacy.
Based on their review of all the available data the committee members made the following recommendations:

For acute treatment of Migraine attacks:

  1. Ibuprofen is effective and should be considered for the acute treatment of Migraine attacks in children (over 6).
  2. Acetaminophen is probably effective and should be considered for the acute treatment of Migraine attacks in children.
  3. Sumatriptan nasal spray is effective and should be considered for the acute treatment of Migraine attacks in adolescents (over 12).
  4. There were no data, positive or negative, regarding the use of any oral triptans in children or adolescents
  5. There are inadequate data to determine the efficacy of subcutaneous sumatriptan.

For daily preventive therapy:

  1. Flunarizine is probably effective and could be considered but is not available in the United States.
  2. There is insufficient evidence to make any recommendations concerning the use of cyproheptadine, amitriptyline, divalproex sodium, topiramate, or levetiracetam.
  3. Because the evidence is conflicting, recommendations cannot be made concerning propranolol or trazodone.
  4. Pizotifen (Sandomigraine) and nimodipine (Nimotop®) and clonidine did not show efficacy and are not recommended.

Pediatric head pain specialist Dr. Donald W. Lewis, of Children's Hospital of the King's Daughters in Norfolk, Virginia, was the lead author on their findings. In an interview, he commented:

"This is one of those unfortunate areas where a very common problem has been understudied. There is a lot of denial, among families and among clinicians, that children do get Migraines. We need more clinical trials to see how these medicines work in children. ... One of the themes here is that initial trials have failed. More intense and innovative research needs to be done."2

Given the lack of good news from the study and guidelines, it's encouraging that he had other comments:

"The treatment for many problems in children is not just drugs. It is often a lifestyle change," Lewis says. "Biobehavioral Migraine treatment is a whole-package approach to managing these children. For every patient, treatment has to be individually tailored. We may not commit a child to daily medication right off the bat."

Essentially, he's talking about the same lifestyle change adult Migraineurs need to look at as well to avoid triggers. If your child is a Migraineur, you can help them in this regard by looking out for...

  • their sleep patterns. Migraineurs do best with a set time to go to bed and get up every morning, regardless or weekends, holidays, vacations, etc.
  • caffeine consumption. Sodas can be a problem for both children and adolescents. More and more, adolescents are drinking coffee and coffee drinks. Iced tea is also a culprit.
  • dietary considerations. Help them keep a Migraine diary and look for trigger foods. A balanced diet, easy on the fast food and junk food is especially helpful.
  • exercise. Good general health helps every Migraineur.
  • stress. While stress itself isn't an actual Migraine trigger, it is an exacerbating factor, and will make kids more susceptible to their Migraine triggers. Try to keep an eye on your child's stress level.

Summary:

Unfortunately, these new guidelines provide doctors with little that's of immediate use other than the safety of sumatriptan nasal spray for adolescents. In their report, Lewis et al call for the safety and efficacy of medications currently used by adult Migraineurs to be established for children and adolescents. They also note that it's essential that clinical trials be conducted to find effective preventive medications and that there are no studies of Status Migrainous (prolonged Migraine attack lasting longer than 72 hours) in children and adolescents. It's important to remember that, despite these findings, some children and adolescents are responding to preventive medications used by adults and prescribed by their doctors. Until therapies are developed more specifically for children, the best we can do is help them with their lifestyle and work with their doctors to find the most effective treatment regimen possible for each individual young Migraineur.

 


1 Lewis, D., MD; Ashwal, S., MD; Hershey, A.,MD; Hirtz, D., MD; Yonker, M., MD; and Silberstein, S. MD.  "Pharmacological treatment of Migraine headache in children and adolescents." Neurology 2004;63:2215-2224.

2 DeNoon, Daniel. "Kids' Migraines: Over-the-Counter Drugs Best." WebMd Medical News. December 27, 2004.

Last Updated August 21, 2004

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