Treatment of Acute Migraine in the Pediatric Population

Abstract

The recognition of the diagnosis of migraine in the pediatric population is increasing. Early and aggressive treatment of migraine in children and adolescents with the use of over-the-counter medications has proven effective. In addition, the off-label use of many migraine-specific medications is often accepted in the absence of sufficient evidence-based trials. Mild to severe cases of migraine should be treated with NSAIDs, with triptans used for moderate to severe headaches that are unresponsive to over-the-counter therapy. Rescue medication including dihydroergotamine (DHE) should be used for intractable migraines, preferably in the hospital setting. In patients with associated symptoms of nausea and vomiting, antiemetics with antidopaminergic properties can be helpful through their action on central migraine generation. Furthermore, patients and families should be educated about nonpharmacologic aspects of management such as preventing episodic migraine through lifestyle modification and avoidance of triggers.

Headache in Children and Adolescents

“…Triptans are contraindicated in patient treated with ergotamine within 24 hours and within 2 weeks of treatment with monoamine oxidase inhibitors. Both triptans and ergotamine are contraindicated in hemiplegic migraine [2,87,89] . Preventive treatment needed, if headaches are frequent (>1 headache/ week) or there is more than one disabling headache/month (missing school, home, or social activities, or a PedMIDAS score >20) with the goal to reduce frequency (1-2 headaches or fewer per month) and disability (PedMIDAS score <10).…”

“…The most commonly used preventive therapy for headache and migraine is amitriptyline. Other prophylactic medicines are topiramate, valproic acid, levetiracetam, gabapentin, lamotrigine, zonisamide, pregabalin, cyproheptadine, and propranolol [2,87,[89][90] . Among these, only topiramate is approved by FDA, in adolescents 12-17 years of age [91] .Neutraceuticals including riboflavin, coenzyme Q10, butterbur and magnesium showed some efficacy [1,[92][93][94] .…”

Pediatric Posttraumatic Headache

“…31 Adherence can be optimized by educating the patient and family about lifestyle changes, the proper use of acute and prophylactic medications and establishing realistic expectations including reasonable estimate of recovery. 27,32,33 …”

“…Patients are often counseled on the importance of keeping well hydrated as dehydration is commonly identified as a headache trigger. 33,36 Non-pharmacologic treatments such as behavioral and relaxation therapy, biofeedback and coping skills have demonstrated good evidence in children and adolescents with chronic headaches. 37,38 Combining cognitive behavioral therapy (CBT) with relaxation training and biofeedback may increase treatment efficacy, especially in patients with psychiatric comorbidities, high levels of stress, or poor coping skills.…”

The McMaster Pediatric Migraine Questionnaire: A Prospective Validation Study

“…[1][2][3] It is well known that of the primary headache disorders, pediatric migraine has the greatest effect on a child's quality of life. It has known effects on school performance and attendance, socialization, and family function.…”