Prophylaxis of Migraine in Children and Adolescents

Abstract

While it has been established that headaches in the pediatric age group are relatively common, the characterization of headache disorders and their treatment in this group has historically been limited. Due to the paucity of controlled studies on prophylaxis of the primary headache disorders in children, the diagnosis of migraine often rests on criteria similar to those used in adults. Data from adult studies are often extrapolated and applied to the pediatric patient. Although it appears that many prophylactic agents are safe, well tolerated and efficacious in children, currently only topiramate is FDA-approved for use in patients 12 years and over. As a result, despite often experiencing significant disability, many children who present to their physician with migraines do not receive preventive therapy. One-third of adolescents meet the criteria for warranting prophylactic therapy, yet few are offered a preventative medication. Moreover, controlled clinical trials investigating the use of both abortive and prophylactic medications in children have suffered from high placebo response rates. A diverse group of medications are used to prevent migraine attacks, including antidepressants, antiepileptics, antihistamines and antihypertensive agents, yet there still remains a serious lack of controlled studies on the pharmacological treatment of pediatric migraine.

Factors Influencing Response to Pharmacologic Treatment of Migraine in a Pediatric Headache Clinic

“…Patients taking amitriptyline are warned that the drug may cause drowsiness; therefore, we try to start with a low dose. Topiramate is given to children aged 12 years or older; it is not FDA‐approved for use in younger patients . We avoid giving it to children with a low body mass index because it reduces appetite, and to children with a suspected psychiatric comorbidity, such as depression, because it may increase suicidality.…”

“…Topiramate is given to children aged 12 years or older; it is not FDA-approved for use in younger patients. 7 We avoid giving it to children with a low body mass index because it reduces appetite, and to children with a suspected psychiatric comorbidity, such as depression, because it may increase suicidality. Patients are warned about other side effects of topiramate, namely lack of concentration, drowsiness, nervousness, and dizziness.…”

Recommendations on the Use of Anti‐CGRP Monoclonal Antibodies in Children and Adolescents

“…If improvement is seen, we recommend continuing the medication in an attempt to reach a patient‐centered overall treatment goal of fewer than 1 headache per week . If this goal is attained, the patient can be continued on the medication for another few months and then efforts should be made to wean off the medication …”

Pediatric Posttraumatic Headache

“…44,45 When ibuprofen and acetaminophen are not effective in aborting a migrainous headache, or if the headaches are long-lasting and require repeated dosing, migraine specific medications, particularly the triptans, can be administered. Erickson 29 performed an observational study of adult soldiers with posttraumatic headaches, 96% of which demonstrated migrainous features, who were given triptans for abortive management of their headaches.…”