AAN, AHS Release Updated Guidance on Short-Term Migraine Treatment in Children, Adolescents

The American Academy of Neurology (AAN) and the American Headache Society (AHS) released updated guidance on short-term treatment of migraine in children and adolescents. The original guidance was released in 2004, and these new recommendations include establishing an early diagnosis and providing counsel on lifestyle and nonpharmacologic treatment options.

“Pediatric migraine is a common and potentially disabling disorder with an 8% to 24% prevalence in school-aged children,” and more than a quarter of children with migraine report moderate or severe disability associated with the condition, the authors said.

To determine which advances ought to be included in the guidance, the researchers preformed a literature search on Ovid MEDLINE for articles published between December 2003 and August 2017. All studies involving at least 20 participants with migraine, where at least 90% of the cohort was between the ages of 0 and 18 and treatment was compared with placebo were considered. This criterion yielded trials focused on short-term use of triptan medications.

A panel then assigned levels of obligation based on the evidence’s confidence, determined by a modified Grading Recommendations Assessment. Strength of the evidence, financial, risk, accessibility, and patient preference factors were all taken into consideration.

In addition to establishing a specific headache type as primary, secondary, or other, the guidance recommends clinicians inquire about premonitory and aura symptoms, headache description, associated symptoms, and pain-associated disability.

As far as treatment goes, ibuprofen (10 mg/kg) should be prescribed as an initial option, followed by antiemetic treatments for children and adolescents with prominent nausea or vomiting. For short-term pain management in adolescents, several triptans can be prescribed, including sumatriptan-naproxen oral tablets (in dosages of 10/60, 30/180, or 85/500 mg), zolmitriptan nasal spray (5 mg), sumatriptan nasal spray (20 mg), rizatriptan oral dissolving tablets (5 or 10 mg), or almotriptan oral tablets (6.25 or 12.5 mg).

If a headache reoccurs within 24 hours of treatment, triptans can be readministered to this population. However, “if migraine is incompletely responsive to triptans, a nonsteroidal anti-inflammatory drug (NSAID), such as ibuprofen or naproxen, should be taken together with the triptan to improve pain response. This recommendation does not pertain to the sumatriptan-naproxen combination,” the authors said.

Additional recommendations include the following:

• Use ibuprofen or acetaminophen 14 or fewer days per month and triptans 9 or fewer days per month, to avoid medication overuse,
• Avoid using triptans in patients with a history of ischemic vascular disease or accessory conduction pathway disorders
• Short-term migraine treatments are more effective when the pain is still mild
• Clinicians should offer individualized treatment plans based on patient symptoms and preference

If headache intensity peaks rapidly, a patient experiences nausea and/or vomiting, or oral formulations have been ineffective, triptans with a nonoral route may be prescribed. Authors note there is no evidence to support the use of opioids for pediatric migraine.

Aside from pharmacological interventions, patients are encouraged to keep a headache diary to assess treatment response, while physicians should provide counseling on lifestyle modification and evaluation of migraine triggers in patients.

“Providing symptom-specific short-term treatment options to pediatric and adolescent patients has the advantage of earlier migraine attack treatment, as well as limiting reliance on emergency department visits,” the researchers said. They continue, “With more available medications, however, patients and clinicians have to be mindful of headaches from medication overuse and possible triptan contraindications or adverse effects.”

In future studies, investigators ought to address high placebo response rates common in pediatric triptan trials. This could be managed by introducing novel trial designs, examining short-term therapies for use in refractory-headache populations, and evaluating alternative delivery routes for those with nausea or unable to swallow tablets.

Ditans, gepants, and nutraceuticals should all be evaluated as potential abortive migraine medications for pediatric populations. In addition, in 2019, 2 migraine prevention agents, cinnarizine and sodium valproate, were shown to be safe and effective in reducing the incidence and severity of migraine within children and adolescents.

“New areas of research can lead to earlier identification and treatment of migraine in children and adolescents and improve their quality of life,” the researchers conclude.

Reference:

Patniyot I, Qubty W. Short-term treatment of migraine in children and adolescents. JAMA Pediatr. Published online June 22, 2020. doi:10.1001/jamapediatrics.2020.1422