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Offer ibuprofen1,2 for established migraine3 in children; offer ibuprofen or triptans for adolescents. Adjunctive nausea tx prn. Lifestyle mod to ↓triggers - Tx w/ 1st-line drug early in HA course: ibuprofen for children;1,2 ibuprofen or triptans (alone or w/ NSAID) for adolescents, per AAN/AHS,1 EHF.2 If migraine w/ aura,3 take acute med @ HA onset1,2 Children w/ short-duration attacks may respond to bedrest alone, per EHF2
- If not responsive to initial tx or SEs not tolerated: Use a different triptan;1,2 offer non-oral formulations if HA peaks rapidly,1 add ibuprofen1 or naproxen1,2 to triptan1 for adolescents
- If nausea: Use non-oral formulations if available;1 provide antiemetic meds for children/adolescents prn, per AAN/AHS,1 EHF2
- If complex migraine (eg, w/ hemiplegia or brainstem aura): Consider HA specialist referral, per AAN/AHS1
- If HA tx successful but recurs w/in 24h: Take 2nd dose of acute migraine med, per AAH/AHS,1 EHF2
- Don’t use opioids: No evidence supports opioid use in pedi migraine.1,2,4 Don't use barbiturates or ergotamine; acetaminophen alone isn't 1st line; homeopathy unproven, per EHF2
Counsel/educate to reduce future HA episodes1 - Avoid med overuse3 which can ↑HA frequency via med-overuse HA1-3
- Counsel family on lifestyle;2,4 identify/avoid HA triggers (menstrual-related, etc)2 and HA1 exacerbators. CBT benefits sx mgmt, per EHF2
- CBT benefits sx mgmt, per EHF,2 SG5
Footnotes 1 AAN 2019 (Acute Tx). Oskoui M, et al. Practice Guideline Update Summary: Acute Treatment of Migraine in Children and Adolescents. Headache. 2019. Sept;59(8):1158-1173. PDF
• Ibuprofen:10 mg/kg (SOL or TAB).
• Oral naproxen + sumatriptan more likely vs placebo to result in HA-free status @ 2h; oral naproxen alone not studied in children.
• Triptan formulations for adolescents: sumatriptan/naproxen TAB (10/60, 30/180, 85/500), zolmitriptan nasal (5 mg), sumatriptan nasal (20 mg), rizatriptan ODT (5 or 10 mg), or almotriptan OT (6.25 or 12.5 mg).
• FDA-approved triptan by age: sumatriptan/naproxen, ≥12 yo; almotriptan, ≥12 yo; zolmitriptan nasal, ≥12 yo, rizatriptan, 6-17 yo.
• Migraine aura: Triptan safe to take during typical aura, but med taken w/ HA onset provides optimal relief.
• Counsel family: Trialing a series of meds may be needed before finding optimal tx.
2 EHF 2019. Steiner TJ, et al. Aids to Management of Headache Disorders in Primary Care (2nd edition): On Behalf of the European Headache Federation and Lifting the Burden: The Global Campaign Against Headache. J Headache Pain. 2019. May 21;20(1):57. PDF
• Acute tx in children: Ibuprofen 200–400 mg per age/wt. In children <12 yo, no migraine drug has proven efficacy. Take soluable/ODT forms, early in attack. Use non-oral forms if emesis.
• Acute tx in adolescents (12-17 yo): Sumatriptan nasal spray 10 mg, zolmitriptan nasal spray 2.5 mg and 5 mg have efficacy. Triptans more effective taken @HA onset/ while HA is still mild—but not during aura. If non-response to triptan, 2nd dose taken 2+ hr later may be effective. May need to try several triptans/different forms. Sumatriptan efficacy may be ↑ by combo w/ naproxen. Don’t use triptans ≥10 days/mo, to avoid med-overuse HA.
• Antiemetic: (Epocrates note: Domperidone suggested by EHF; however, available in U.S. only via FDA expanded-access IND application.)
• Lifestyle/Triggers: Triggers include menstruation cycle, irreg lifestyle (sleep, stress, missed meals). No evidence that gluten-free, lactose-free, ketogenic, or other specific diet improves HA. In general, limited data on exercise for migraine, but regular exercise recommended.
• Menstrual-related migraine: Some pts report improvement w/ hormonal contraceptives (esp if continuous); however, others experience aggravation or new-onset migraine upon starting combined hormonal contraceptives. If aura present, offer progestogen-only (or nonhormonal) contraception, since ethinylestradiol and migraine w/ aura are both independent risk factors for stroke in young women.
• CBT benefits sx mgmt, coping strategies.
3 IHS 2018. Headache Classification Committee of the International Headache Society (IHS). The International Classification of Headache Disorders, 3rd edition. Cephalalgia. 2018. Jan;38(1):1-211. PDF
• Pedi migraine: ≥5 HAs over past yr, lasting 2h-72h when untreated, ≥2 of: pulsatile quality, unilateral, worse w/ activity/limits activity, mod/sev intensity, and ≥1 of: nausea, vomiting, photophobia, phonophobia. Sx can be inferred by behaviors of younger children. Exclude secondary HA, suggested by sudden change in HA character, papilledema, focal deficits, or seizures.
• Med-overuse HA cautions: NSAID or acetaminophen use ≥15 days/mo, ≥3mo; triptan use ≥10 days/mo, ≥3mo; and combo meds w/ triptan, ergot, or opioid use ≥10/mo, ≥3mo.
4 AAN 2019 (Preventive Tx). Oskoui M, et al. Practice Guideline Update Summary: Pharmacologic Treatment for Pediatric Migraine Prevention. Headache. 2019. Sept;59(8):1144-1157. PDF
• Lifestyle: ↓weight if overweight, ↑physical activity, ↓caffeine and alcohol, improve sleep habits, ↓tobacco exposure, address depression if present.
5 SG 2018. Short Life Working Group for Paediatric Pain. Management of Chronic Pain in Children and Young People. A National Clinical Guideline. The Scottish Government. March 2018. PDF
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Chronic/recurrent migraines
Consider preventive tx1,2 if migraine3 frequency/severity is disabling.2 Use shared decision-making on 1st-line drug + CBT; counsel on lifestyle/triggers - Offer 1st-line tx: topiramate,1 propranolol, or combo amitriptyline1,4 + CBT; minimum med trial 2+ mo;1 factor comorbidities (eg, topiramate,1 an appetite suppressant, if obese), per AAN/AHS.1 CBT benefits sx mgmt support, per EHF2
- If not responsive to 1st drug trial: Consider 2+ mo trial w/ different 1st-line agent, per AAN/AHS
- If med-overuse HA (may coexist w/ chronic migraine):2 Stop overused med2,3 and start 1st-line prevention tx, per AAN/AHS1
- If migraine control established: Counsel re risk/benefits of stopping meds1 Consider tapered withdrawal after 6mo to <1y, per EHF2
- Don’t use opioids1,2 Not recommended or limited evidence; barbiturates, onabotalinumtoxinA, herbals, nutraceuticals, homeopathy, acupuncture, devices, per EHF2
Counsel family, screen for comorbid disorders - Educate that prevention meds not superior to placebo in pedi trials1 (including adult prevention meds)5 per AAH/AHS
- Screen children/adolescents w/ migraine for mood/anxiety disorders2
- CBT benefits sx mgmt, per EHF;2 less evidence for computer-based, per SG4
- Counsel on lifestyle:1,2 Identify/avoid HA triggers (eg, menstrual-related,2 etc) and HA exacerbators, per AAN/AHS,1 EHF2
Footnotes 1 AAN 2019 (Preventive Tx). Oskoui M, et al. Practice Guideline Update Summary: Pharmacologic Treatment for Pediatric Migraine Prevention. Headache. 2019. Sept;59(8):1144-1157. PDF• PedMIDAS scores: >30 indicates mod/sev migraine disability, ↑risk of mood/anxiety disorders, and ↑severity/frequency of HAs.
• Lifestyle: ↓weight if overweight, ↑physical activity, ↓caffeine and alcohol, improve sleep habits, ↓tobacco exposure, address depression if present.
• Amitriptyline w/o CBT: Evidence insufficient.
• Topiramate: Counsel pts of childbearing potential on teratogenic effect; may ↓effectiveness of oral combined hormonal contraceptives (esp >200 mg daily); discuss optimal contraception; offer folic acid supplementation.
• High placebo response: In trials, 30%-61% of children on placebo had ≥50% ↓ in HA frequency.
• Migraine prevention meds used in adults. These either aren't superior to placebo in pedi trials or have insufficient evidence: nimodipine, valproate, flunarizine, onabotulinumtoxinA, and amitriptyline w/o CBT.
• Comorbid negative emotional states (anxiety, depression, mental distress): assoc w/ ↑risk of HA persistence in pts w/ recurrent HAs.
2 EHF 2019. Steiner TJ, et al. Aids to Management of Headache Disorders in Primary Care (2nd edition): On Behalf of the European Headache Federation and Lifting the Burden: The Global Campaign Against Headache. J Headache Pain. 2019. May 21;20(1):57. PDF
• Chronic migraine. Suspect if migraine hx 15+ HA days/mo. Often complicated by depression/anxiety, neck/back pain, med overuse. Specialist referral recommended.
• Med-overuse HA (15+ HA days/mo) may coexist w/ chronic migraine; must be managed separately.
• Prophylaxis. Any child/adult w/ migraine not controlled w/ acute tx who has QOL impairment should be offered prophylaxis. Additional indication in children: frequent school absences. Specialist referral indicated.
• Drug prophylaxis. Specialist referral recommended. Start low dose; expect 2-3mo minimum to observe efficacy; failure of 1 drug class doesn’t predict failure of a different drug class. Consider tapered withdrawal after 6mo (<1y) of good control.
• Limited evidence or unproven: Acupuncture (may be placebo effect), devices, homeopathy. Not recommended: onabotalinumtoxinA, surgical procedures, herbals (feverfew, butterbur), nutraceuticals.
• Lifestyle/Triggers: Triggers include menstruation cycle, irreg lifestyle (sleep, stress, missed meals). No evidence that gluten-free, lactose-free, ketogenic, or other specific diet improves HA. In general, limited data on exercise for migraine, but regular exercise recommended.
• Menstrual-related migraine: Some pts report improvement w/ hormonal contraceptives (esp if continuous); however, others experience aggravation or new-onset migraine upon starting combined hormonal contraceptives. If aura present, offer progestogen-only (or nonhormonal) contraception, since ethinylestradiol and migraine w/ aura are both independent risk factors for stroke in young women.
• CBT benefits sx mgmt, coping strategies.
3 IHS 2018. Headache Classification Committee of the International Headache Society (IHS) The International Classification of Headache Disorders, 3rd edition. Cephalalgia. 2018. Jan;38(1):1-211. PDF
• Pediatric migraine: ≥5 HAs over past yr, lasting 2h-72h untreated, ≥2 of: pulsatile quality, unilateral, worse w/ activity/limits activity, mod/sev intensity; and ≥1 of: nausea, vomiting, photophobia, phonophobia. Sx can be inferred by behaviors of younger children. Exclude secondary HA, suggested by sudden change in HA character, papilledema, focal deficits, or seizures.
• Chronic migraine: (absent med-overuse HA) 15+ HA days/mo for >3mo, of which 8+ days/mo fulfill migraine criteria or responded to migraine-specific drugs.
• Med-overuse HA cautions: NSAID or acetaminophen use ≥15 days/mo, ≥3mo; triptan use ≥10 days/mo, ≥3mo; and combo meds w/ triptan, ergot, or opioid use ≥10/mo, ≥3mo.
4 SG 2018. Short Life Working Group for Paediatric Pain. Management of Chronic Pain in Children and Young People. A National Clinical Guideline. The Scottish Government. March 2018. PDF
• Low-dose amitriptyline. Consider for chronic daily HA.
• CBT for chronic HA: Some evidence for dose-response; evidence for effectiveness of computer-based interventions in children/young people is more limited.
5 AAN/AHS 2012. Silberstein SD, et al. Quality Standards Subcommittee of the American Academy of Neurology and the American Headache Society. Evidence-based Guideline Update: Pharmacologic Treatment for Episodic Migraine Prevention in Adults Neurology. 2012. Apr 24;78(17):1337-45. PDF
• Effective adult migraine prevention meds incl divalproex sodium, sodium valproate, topiramate, metoprolol, propranolol, and timolol; frovatriptan effective for menstrual migraine.
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