Clinical Evidence Handbook

A Publication of BMJ Publishing Group

Migraine Headache in Children

Am Fam Physician. 2009 Dec 15;80(12):1445-1446.

This clinical content conforms to AAFP criteria for evidence-based continuing medical education (EB CME). See CME Quiz on page 1361.

Diagnosis of migraine headache in children can be difficult because it depends on subjective symptoms, and diagnostic criteria are broader than in adults.

  • Migraine occurs in 3 to 10 percent of children and increases with age up to puberty.

  • Migraine spontaneously remits after puberty in one half of children; however, if it begins during adolescence, it may be more likely to persist throughout adulthood.

We do not know whether paracetamol, nonsteroidal anti-inflammatory drugs (NSAIDs), or codeine phosphate relieve the pain of migraine in children, because few studies have been found. Nevertheless, it is widely accepted, good clinical practice that paracetamol, an NSAID such as ibuprofen, or a combination of both is the first-line therapy for headache relief during acute attacks unless contraindicated.

There is increasing evidence that nasal sumatriptan is likely to be beneficial in reducing pain at two hours compared with placebo in children 12 to 17 years of age with persisting headache.

  • Oral rizatriptan may reduce nausea, but it has not been shown to reduce pain compared with placebo.

  • We do not know whether oral zolmitriptan or eletriptan are effective compared with placebo; data regarding zolmitriptan are conflicting and data regarding eletriptan are limited.

We do not know whether antiemetics are beneficial for treating an acute attack of childhood migraine, because we found no studies.

Pizotifen is widely used as prophylaxis in children with migraine, but we found no studies assessing its effectiveness.

  • When used prophylactically, stress management programs may improve headache severity and frequency in the short term compared with no stress management.

  • Studies of beta blockers as prophylaxis in children have had inconsistent results, and propranolol may even increase the duration of headaches compared with placebo.

  • We do not know whether prophylactic dietary manipulation, thermal biofeedback, or progressive muscle relaxation can prevent recurrence of migraine in children.

There is inconclusive evidence that topiramate may be useful as prophylaxis in children with migraine.

Clinical Questions

What are the effects of treatments for acute attacks of migraine headache in children?

Beneficial

5-HT1 antagonists

Likely to be beneficial

Nonsteroidal anti-inflammatory drugs*

Paracetamol*

Unknown effectiveness

Antiemetics

Codeine phosphate

What are the effects of prophylaxis for migraine headache in children?

Likely to be beneficial

Stress management

Unknown effectiveness

Beta blockers

Dietary manipulation

Pizotifen

Progressive muscle relaxation

Thermal biofeedback

Topiramate


*— Based on consensus; no evidence from randomized controlled trials.

Clinical Questions

View Table

Clinical Questions

What are the effects of treatments for acute attacks of migraine headache in children?

Beneficial

5-HT1 antagonists

Likely to be beneficial

Nonsteroidal anti-inflammatory drugs*

Paracetamol*

Unknown effectiveness

Antiemetics

Codeine phosphate

What are the effects of prophylaxis for migraine headache in children?

Likely to be beneficial

Stress management

Unknown effectiveness

Beta blockers

Dietary manipulation

Pizotifen

Progressive muscle relaxation

Thermal biofeedback

Topiramate


*— Based on consensus; no evidence from randomized controlled trials.

Definition

Migraine is defined by the International Headache Society (IHS) as a recurrent headache that occurs with or without aura and that lasts two to 48 hours. It is usually unilateral in nature, pulsating in quality, of moderate or severe intensity, and is aggravated by routine physical activity. Nausea, vomiting, photophobia, and phonophobia are common accompanying symptoms. This review focuses on migraine in children younger than 18 years.

Diagnostic criteria for children are broader than criteria for adults, allowing for a broader range of duration and a broader localization of the pain. Diagnosis is difficult in young children because the condition is defined by subjective symptoms. Studies that do not explicitly use criteria that are congruent with IHS diagnostic criteria (or revised IHS criteria in children younger than 16 years) have been excluded from this review.

Many children with a symptom cluster that includes headache may not perfectly match the IHS classification, but may benefit from medical interventions currently in use. Therefore, a liberal approach to symptomatology is likely to be beneficial in clinical practice.

Incidence

Migraine occurs in 3 to 10 percent of children. It currently affects 50 out of 1,000 school-aged children in the United Kingdom, and an estimated 7.8 million children in the European Union. Studies in resource-poor countries suggest that migraine is the most common diagnosis in children presenting with headache to a medical practitioner. It is rarely diagnosed in children younger than two years because of the symptom-based definition, but its incidence increases steadily with age thereafter. It affects boys and girls similarly before puberty, but girls are more likely to have migraine after puberty.

Etiology

The cause of migraine headaches is unknown. We found few reliable data identifying risk factors or measuring their effects in children. Suggested risk factors include stress, certain foods, menses, and exercise in genetically predisposed children.

Prognosis

We found no reliable data about the prognosis of childhood migraine headache diagnosed by IHS criteria. Psychological factors that contribute to symptoms should be taken into account when considering expectations for treatment success. Not all treatments work for every child—some will not respond to medications with the clearest evidence available from controlled trials to support their use. It has been suggested that more than one half of children have spontaneous remission after puberty. Migraine that develops during adolescence often continues in adulthood, although attacks tend to be less frequent and severe over time.

We found one longitudinal study from Sweden (73 children with “pronounced” migraine and a mean age of six years at onset) with more than 40 years of follow-up, which predated the IHS criteria for migraine headache. The study found that migraine headaches had ceased before 25 years of age in 23 percent of participants. However, by 50 years of age, more than one half of participants continued to have migraine headaches. We found no prospective data examining long-term risks in children with migraine.

Author disclosure: Nothing to disclose.

editor's note: Paracetamol is available as acetaminophen in the United States; pizotifen is not available in the United States.

search date: May 2008

Adapted with permission from Barnes N, James E. Migraine headache in children. Clin Evid Handbook. June 2009:96–97. Please visit http://www.clinicalevidence.bmj.com for full text and references.

 

This is one in a series of chapters excerpted from the Clinical Evidence Handbook, published by the BMJ Publishing Group, London, U.K. The medical information contained herein is the most accurate available at the date of publication. More updated and comprehensive information on this topic may be available in future print editions of the Clinical Evidence Handbook, as well as online at http://www.clinicalevidence.bmj.com (subscription required). Those who receive a complimentary print copy of the Clinical Evidence Handbook from United Health Foundation can gain complimentary online access by registering on the Web site using the ISBN number of their book.


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