Practice Guidelines

Migraines in Children: Recommendations for Acute and Preventive Treatment

 

Am Fam Physician. 2020 May 1;101(9):569-571.

Author disclosure: No relevant financial affiliations.

Key Points for Practice

• No medications have been shown to be more effective than placebo for preventing migraine in children and adolescents.

• CBT appears to be effective for reducing migraine frequency in children and adolescents.

• First-line acute migraine treatment in children is ibuprofen; adolescents may benefit from sumatriptan/naproxen tablets, zolmitriptan nasal spray, sumatriptan nasal spray, rizatriptan, or almotriptan.

• Overuse of acute medication to treat migraines increases headache frequency.

From the AFP Editors

Updated recommendations for the prevention and treatment of migraines in children and adolescents were recently published by the American Academy of Neurology and the American Headache Society, and they are based on a systematic review of new evidence published between January 2003 and August 2017. Migraines are common, with a prevalence of 1% to 3% in children three to seven years of age, 4% to 11% in children seven to 11 years of age, and 8% to 23% in those 15 years of age. Prevention should be considered if headaches occur frequently, are severe, and result in significant disability. Migraine-related disability is determined using an evaluation tool such as the Pediatric Migraine Disability Assessment, a six-question scale that measures migraine impact over three months (Table 11,2).

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TABLE 1.

Pediatric Migraine Disability Assessment (PedMIDAS)

In the past three months: How many full days of school did you miss because of headaches? How many partial days of school did you miss because of headaches? How many days did you go to school but functioned at less than one-half of your ability because of a headache? How many days were you not able to do things at home because of a headache? How many days were you not able to participate in other activities because of a headache? How many days did you participate in other activities but functioned at less than one-half of your ability because of headaches?

Total the answers of all questions to get the PedMIDAS score.


PedMIDAS disability grades

Score Grade Disability

0 to 10

1

Little to none

11 to 30

2

Mild

31 to 50

3

Moderate

> 50

4

Severe


Information from references 1 and 2.

TABLE 1.

Pediatric Migraine Disability Assessment (PedMIDAS)

In the past three months: How many full days of school did you miss because of headaches? How many partial days of school did you miss because of headaches? How many days did you go to school but functioned at less than one-half of your ability because of a headache? How many days were you not able to do things at home because of a headache? How many days were you not able to participate in other activities because of a headache? How many days did you participate in other activities but functioned at less than one-half of your ability because of headaches?

Total the answers of all questions to get the PedMIDAS score.


PedMIDAS disability grades

Score Grade Disability

0 to 10

1

Little to none

11 to 30

2

Mild

31 to 50

3

Moderate

> 50

4

Severe


Information from references 1 and 2.

Pharmacologic Preventive Treatment

Although the primary outcome in studies of migraine prevention is the percentage of children who achieve a 50% reduction in headache frequency, other important outcomes include a general reduction in frequency, the number of headache days, headache severity, and disability.

TOPIRAMATE (TOPAMAX)

Children and adolescents treated with topiramate may have a decrease in migraine frequency or headache days compared with placebo, but they are as likely as children who receive placebo to have a 50% reduction in headache frequency or a decrease in migraine-related disability.

OTHER PREVENTIVE MEDICATIONS

Extended-release divalproex (Depakote), amitriptyline, and propranolol lack evidence that they are more effective than placebo at reducing headache frequency or disability in children.

ONABOTULINUMTOXINA (BOTOX)

OnabotulinumtoxinA injections are more effective than placebo in adults with chronic migraine (i.e., more than 15 episodes per month) but have shown no benefit in adolescents.

Pharmacologic Preventive Treatment Plus Cognitive Behavior Therapy (CBT)

AMITRIPTYLINE WITH CBT

Children and adolescents 10 to 17 years of age with chronic migraine who are treated with amitriptyline plus CBT are more likely than those receiving amitriptyline and headache education to achieve a 50% reduction in headache frequency and a reduction in headache-related disability.

Prevention Recommendations

Counseling and education are important for patients and their families, especially because of the lack of useful pharmacologic therapy. Behavioral factors that influence the frequency of headaches in adolescents are obesity and overweight, caffeine and alcohol use, lack of physical activity, poor sleeping habits, and tobacco exposure. Losing weight has been shown to reduce headaches in overweight children. Depression is associated with greater headache disability

Author disclosure: No relevant financial affiliations.

References

1. Hershey AD, Powers SW, Vockell AL, et al. PedMIDAS: development of a questionnaire to assess disability of migraines in children. Neurology. 2001;57(11):2034–2039.

2. Hershey AD, Powers SW, Vockell AL, et al. Development of a patient-based grading scale for PedMIDAS. Cephalalgia. 2004;24(10):844–849.

Coverage of guidelines from other organizations does not imply endorsement by AFP or the AAFP.

This series is coordinated by Sumi Sexton, MD, editor-in-chief.

A collection of Practice Guidelines published in AFP is available at https://www.aafp.org/afp/practguide.

 

 

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