Featured Reading 1: Acute Treatment of Migraines

Oskoui M, Pringsheim T, Holler-Managan Y, Potrebic S, Billinghurst L, Gloss D, Hershey AD, Licking N, Sowell M, Victorio MC, Gersz EM, Leininger E, Zanitsch H, Yonker M, Mack K. Practice guideline update summary: Acute treatment of migraine in children and adolescents: Report of the Guideline Development, Dissemination, and Implementation Subcommittee of the American Academy of Neurology and the American Headache Society. Neurology. 2019 Sep 10;93(11):487-499. doi: 10.1212/WNL.0000000000008095. Epub 2019 Aug 14. Review. PubMed PMID: 31413171.
https://pubmed.ncbi.nlm.nih.gov/31413171/

ESTABLISHING A MIGRAINE DIAGNOSIS

The diagnosis of pediatric migraine must include at least 5 headaches over the past year that last 2-72 hours when untreated with at least 2 of the following 4 additional features:

• Pulsatile quality
• Unilateral
• Worsening with activity or limiting activity
• Moderate to severe in intensity

The headache is often associated with nausea, vomiting, photophobia, or phonophobia. Aura’s can occur in about 1/3 of children and precede the headache by 5-60 minutes.

ACUTE MIGRAINE TREATMENT

Early treatment (< 1 hour from headache onset) improves pain-free rates. Start with non-prescription oral analgesics (acetaminophen, ibuprofen, and naproxen). Triptans can be prescribed if the patient has failed OTC treatments. Only rizatriptan ODT (5-10 mg) is FDA approved for children as young as 6 years old. For children ≥ 12 years old other triptans such as almotriptan OT (6.25-12.5 mg), sumatriptan NS (20 mg), and zolmitriptan NS (5 mg) can be used. Ergots and oral naproxen alone have not been studied in children. If the child fails 1 triptan, then find an alternative triptan or route of administration. Intranasal sumatriptan and zolmitriptan are absorbed more quickly and have a faster onset of action.
PEARL: If the migraine is successfully treated, but the headache recurs within 24 hours, then take a second dose of the acute migraine medication.
PEARL: Adolescents that do not respond completely to a triptan, should be givenibuprofen or naproxen in addition to the triptan to improve symptoms.

TREATMENT OF MIGRAINE ASSOCIATED SYMPTOMS

Migraine associated symptoms include nausea, vomiting, photophobia, or phonophobia. Antiemetics should be used to treat nausea and vomiting associated with migraine headaches. If severe nausea and vomiting are present, then use intranasal formulations of zolmitriptan and sumatriptan as an abortive acute migraine treatment. Zolmitriptan and sumatriptan/naproxen have also been shown to be responsive to photophobia and phonophobia.

MIGRAINE COUNSELING

Discuss migraine-healthy habits such as lifestyle modification, avoiding migraine triggers and avoidance of medication overuse. Maintain a headache diary to track response to certain triggers and any new therapies.
PEARL: No more than 14 days of ibuprofen or acetaminophen per month.
PEARL: No more than 9 days of triptans per month with no more than 9 days per month of any combination of triptans, analgesics, or opioids for more than 3 months to avoid medication overuse headache.
PEARL: No evidence to support the use of opioids for children with migraines.

TRIPTAN CONTRAINDICATIONS

Avoid in children with a history of ischemic vascular disease (stroke, TIA, MI, severe peripheral vascular disease, ischemic bowel disease, and coronary vasospasm) or cardiac accessory condition pathway disorders (Wolff-Parkinson-White syndrome).
PEARL: In 2004, the American Headache Society consensus statement did not consider these absolute contraindications for triptan use in children.