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19 Articles in Volume 20, Issue #2
20/20 with Peter Staats, MD: The Future of Pain Medicine
Ask the APP: How useful and practical are pain assessment tools?
Ask the PharmD: What are the recommendations for preventing and treating pediatric migraine?
Axial Spondyloarthritis: Updated Medication and Imaging Recommendations
CGRP Monoclonal Antibodies for Chronic Migraine Prevention: Evaluation of Adverse Effects Using A Checklist
Chronic Low Back Pain: Can We Find a Treatment Consensus?
Correspondence: Are ESIs Still Worth It? Benzocaine for Orofacial Pain.
Could Pulsed RF Provide Lasting Chronic Headache Relief in Refractory Patients?
Diagnosis Is Everything: Low Back Pain As a Symptom of an Underlying Condition or Conditions
Editorial: From Just Say No, to Say Now and Say Know
Erenumab and Onabotulinumtoxin A Show Additive Effect in Refractory Chronic Migraine
Experts Roundtable: Finding a Bottom Line in Back Pain Care
Inside the Potential of RNAi to Target the Etiology of hATTR Neuropathy
Muscle Dysfunction in Head and Neck: Pain Causes, Osteopathic Options
New Migraine Medications: Oral Gepants, Ditan Tablet, and More
Root Cause of Sacroiliac Joint Dysfunction: Four-Step Exercise Protocol
The Emotional Impact of Chronic Low Back Pain
The Rise in Tianeptine Abuse: Our Next Kratom Problem?
The Sensory Component of Pain: Modifying Its Emotional and Cognitive Meaning

Ask the PharmD: What are the recommendations for preventing and treating pediatric migraine?

A look at current preventive and acute medications as well as treatment contraindications and related symptoms for migraine in children.
Pages 19-22

The prevalence of migraine in children increases with age and may affect up to 23% of children by age 15, which highlights a need for adequate treatment in these populations. New guidelines were published in 2019, supported by the American Academy of Neurology and the American Headache Society, for the treatment and prevention of migraine in children and adolescents.1,2 The clinical criteria within the International Classification of Headache Disorders should be used to diagnose primary headache disorders. Family history and female sex are risk factors for progression of migraine into adulthood. In adolescents, recurrent headache is often associated with use of caffeine, lack of physical activity, alcohol use, being overweight, poor sleep habits, and tobacco exposure. Avoidance or mitigation of these factors could contribute to decreased migraine frequency.

Migraine in children increases with age and may affect up to 23% of children by age 15. (Image: iStock)

Preventive Pharmacotherapy

If recurrent headaches can be mitigated through lifestyle modifications and acute treatment, preventive therapy may not be necessary. If headaches result in disability according to the Pediatric Migraine Disability Assessment (PedMIDAS), preventive therapy should be considered. This questionnaire is valid in children and adolescents and includes assessment of school days missed, function, and participation in activities over 3 months.2,3 In clinical trials for prevention, inclusion criteria consisted of three to four migraine attacks per month for at least 3 months and a minimum of four headache days per month. A PedMIDAS score of greater than 30 in teenagers indicated a moderate to severe disability. This score translates to an increased frequency and severity of headache as well as a higher risk for anxiety and mood disorders in teenagers.2

Current therapy options from low to high confidence for prevention are listed in Table I.


Amitriptyline (1 mg/kg/d) combined with cognitive behavioral therapy (CBT) carries the highest confidence of efficacy. This combination has been shown to decrease frequency of migraine or headache days and headache frequency by at least 50%. However, this difference has not been shown in amitriptyline in combination with headache education alone.2

In a randomized trial published in 2013, researchers assessed amitriptyline as well as CBT for chronic migraine compared to amitriptyline plus headache education in children and adolescents. The primary endpoint was headache days and the secondary was PedMIDAS score at 20 weeks. Clinical significance was defined as a > 50% reduction in headache days and PedMIDAS score < 20 points. Headache days were reduced significantly by 11.5 days for the amitriptyline plus CBT group vs 6.8 days in the headache education plus amitriptyline group. Scores of the PedMIDAS decreased by 52.7 points versus 38.6 points which was significant in favor of amitriptyline plus CBT.4

Acute Medication

In terms of acute treatment of migraine pain, pharmacologic options recommended in 2004 were mirrored in the 2019 update; although the specific formulations may differ.5 The only category that holds medication in high confidence is the outcome of being pain-free at 2 hours, including sumatriptan/naproxen oral tablet 10/60 mg, 30/180 mg, 85/500 mg, and zolmitriptan nasal spray 5 mg.1

A trial was published in 2012 comparing the efficacy and safety of all three doses of sumatriptan/naproxen combination therapy. This study included patients ages 12 to 17 years with two to eight migraine attacks per month for 6 months that typically lasted more than 3 hours when untreated. The primary endpoint was being pain-free at 2 hours. Rates of pain-free status were significantly higher in all three treatment groups compared to placebo. A post-hoc analysis found no differences among the three dosing regimens. Two-hour photophobia-free and phonophobia-free status were significant in the 85/500 mg group compared to placebo. Additionally, pain-free status was sustained to 24 hours in the 85/500 mg group.6 In the triptan class, while it is safe to take these medications during the aura preceding a migraine, it may be more effective when taken at the start of pain.1 Table II summarizes the acute treatment options recommended in the new guidelines. Generally, triptans are avoided as first-line options until non-prescription options (ie, acetaminophen, ibuprofen) have failed. For consideration of triptans, the safety profile should be weighed against the clinical benefits of use.

Contraindications and Adverse Effects

While it is positive that we have treatment options for patients with chronic migraine, it is also important to consider risks associated with medication use. Amitriptyline has the highest level of evidence in prevention so it is important to note that it carries a black box warning in children and adolescents to increase suicidal thoughts and behavior.7 Topiramate is also a preventative treatment option, however, it has well documented teratogenic effects and should not be used in pregnancy or those with child-bearing potential without adequate birth control methods. At the 200 mg/day dosing, topiramate does not interact with oral combined hormonal contraceptives, however at higher doses the effectiveness of the oral contraceptives can be compromised.3 Many of the recommended treatments are formulated as a triptan/NSAID combination and fetal risk cannot be ruled out in pregnancy for either of these medications.7

Medication overuse headache (MOH) has been associated with the overuse of medications for treatment of migraine; although this association has not been established in children. Neither ibuprofen nor acetaminophen should be used more than 14 days per month and triptans no more than 9 days per month to avoid the possibility of MOH. In addition, any combination of opioids, triptans, or analgesics should be limited to 9 days per month.1

Treating Related Symptoms

Treating the pain associated with chronic migraine is the mainstay of therapy but other symptoms can decrease quality of life. These symptoms include photophobia, phonophobia, nausea, and vomiting. Zolmitriptan nasal spray shows moderate confidence in reducing photophobia and phonophobia at 30 minutes, whereas the sumatriptan/naproxen oral tablets 10/60 mg and 85/500 mg have shown relief at 2 hours in these symptoms (see Table III).



Clinical Takeaways

Although there is medication therapy to treat chronic migraine, symptoms can be mitigated with lifestyle modifications especially in the pediatric and adolescent population due to unwanted adverse effects of drug therapy. Prevention of migraine may be necessary in some patients based on the PedMIDAS score. Amitriptyline combined with CBT is the first recommendation for prevention; however, this drug carries a black box warning of increased risk of suicidal thoughts and behaviors in children and adolescents. Acute treatment options have expanded. Sumatriptan/naproxen combination tablets, and zolmitriptan nasal spray are the highest confidence recommendations for adolescents, however, both should be avoided in pregnancy.

Not all recommendations made by the current guideline have the highest confidence in support of efficacy, and lower quality evidence is all that exists for support of some options. Choice of therapy should be guided by efficacy and safety, including patient-specific factors, such as age, cost, and previously trialed therapies. 

Last updated on: May 14, 2020
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