The Use of Triptans for Pediatric Migraines

Abstract

Migraine headaches frequently occur in the pediatric population, with a prevalence of 3% in children 2-7 years of age, 4-11% in children 7-11 years of age, and 8-23% in children 11 years of age and older. Migraine without aura is more than twice as common as migraine with aura in children. Headaches are the third leading cause of emergency room referrals and rank in the top five health problems of children. The 2004 American Academy of Neurology's treatment parameter for migraine in children and adolescents recommended that nasal sumatriptan be considered for acute treatment; however, data were lacking to make a decision regarding the available oral triptans at that time. The more recently released European guidelines discuss three different triptans for use in children but no specific triptan was recommended. Currently, six of the seven available triptans have been studied for efficacy and safety in the pediatric population; however, only a few well controlled clinical studies have been conducted. Sumatriptan has the most available data on outcomes in general, with nasal sumatriptan showing the most positive results. Nasal sumatriptan is approved in children older than 12 years of age in Europe. Oral sumatriptan does not show any clinical benefit versus placebo in children. Rizatriptan and zolmitriptan have conflicting efficacy and safety data, with most studies favoring the use of oral rizatriptan and nasal zolmitriptan. Almotriptan is the first triptan to obtain a US FDA indication in adolescents with migraines lasting 4 or more hours. This approval was based upon two studies, one large clinical trial and one very small, open-label, pilot study. At this time, there are insufficient data to recommend naratriptan and eletriptan for first- or second-line use in pediatric patients with migraines. There are currently no efficacy data for frovatriptan in pediatric patients, which limits its use in this population. Adverse effects of triptans and pharmacokinetic data in children and adolescents are similar to those in adults. The triptan class should be considered as an acute treatment option for children and adolescents with migraines, although their use is mostly 'off-label'. Of the available triptans, there are more positive efficacy data for sumatriptan and zolmitriptan nasal sprays, and rizatriptan and almotriptan tablets than for the other triptans.

Efficacy and tolerability of zolmitriptan oro-dispersible wafer in treatment of childhood migraine: Table 1

“…The main side effect reported was nausea due to bad taste which was experienced by two patients (14.3%), lower than rates of bad taste reported with intranasal sumatriptan (25.7%) and comparable with nausea associated with other 5-HT agonist use 8 18…”

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.…”

Key differences between triptans relate to their pharmacokinetic profiles and available formulations

“…[1] Some triptans can be more effective than comparators at higher doses, but higher doses are generally associated with increased adverse events. [24] In a recent review of the studies of the efficacy of triptans in treating migraine in paediatric patients, the agents with the most positive data were sumatriptan nasal spray (in children aged ‡5 years), zolmitriptan nasal spray (in children aged ‡12 years), rizatriptan tablets (in children aged ‡ 6 years) and almotriptan tablets (in children aged ‡11 years). [24] In a recent review of the studies of the efficacy of triptans in treating migraine in paediatric patients, the agents with the most positive data were sumatriptan nasal spray (in children aged ‡5 years), zolmitriptan nasal spray (in children aged ‡12 years), rizatriptan tablets (in children aged ‡ 6 years) and almotriptan tablets (in children aged ‡11 years).…”