Migraine can be adequately treated when young patients and their families work closely with their physician and allied healthcare professionals. The management of pediatric migraine includes a comprehensive approach, using both pharmacological and non-pharmacological therapies. Therapy discussion often includes reviewing dietary triggers, limiting caffeine, maintaining a normal BMI (body mass index) and emphasizing the importance of using protective headgear to avoid head trauma during certain physical activities. The comprehensive approach also includes behavior modification programs, exercise protocols, and addressing healthy sleep patterns.
The acute therapies used in the pediatric population should be implemented once it is clear that the headache is migraine. The goal is complete relief of pain, and ideally all symptoms, within one to two hours. Currently, Almotriptan is the only triptan presently approved by the FDA for the treatment of migraine pain in adolescents 12 years and older. The American Academy of Neurology’s 2004 practice parameter for migraine in children and adolescents recommended that nasal sumatriptan be considered for treatment in children and adolescents. Nasal sumatriptan has been approved for use in adolescents 12 years and older in Europe. The 2009 European migraine guidelines discusses positive data with sumatriptan and zolmitriptan nasal sprays and oral zolmitriptan and rizatriptan in children, but do not recommend one specific triptan. Use the lowest initial available triptan dosage first and increase dosage as clinically indicated.
Prescribing considerations for triptans include, but are not limited to, prior evaluation for patients with risk of coronary artery disease, peripheral vascular syndromes, or some other significant underlying cardiovascular disease. Various medications have data supporting their effectiveness for relieving migraine in adolescents over age 15. Such medications include nonsteroidal anti-inflammatory agents (e.g. ibuprofen and naproxen sodium) and aspirin. It is recommended to begin acute treatment as early in the migraine attack as possible.
Analgesics or acute medications of any type should not be used more than twice per week, unless the patient is under medical supervision. Headaches requiring treatment more than once per week may require better preventative treatment methods, such as supplementation with magnesium, riboflavin and coenzyme Q-10 (appropriate dosages of these supplements have not been determined in children).
There is currently no FDA-approved preventative medicine for use in children. Studies of antiepileptic drugs, such as topiramate, have shown various levels of efficacy and good tolerability. Medications approved for adults have been used off-label effectively for children. In these cases, adjustments must be made in dosing to address potential side effects in children.
When does one start and stop preventative treatment? Preventative treatment should be initiated when a child has more than two to three migraines per month that are not fully controlled with acute medicine. The goal of preventative treatment is to reduce headache frequency to once or twice per month or less over three to six months, and then to discontinue preventative therapy as soon as possible. Fortunately, not all adolescents will experience migraines throughout their lifetime, but up to 70% will have some remaining symptoms, whether persistent or episodic.
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