Routine treatments for migraine include the following 5 methods that are described more fully below: (1) intermittent headache medications including analgesics: acetaminophen with a dosage of at least 20 mg/kg per dose, ibuprofen, and aspirin (in teenagers not thought to be at risk for Reye syndrome) or triptans (eg, sumatriptan, zolmitriptan); (2) antinausea agents: promethazine 12.5 to 25 mg (oral, rectal, or topical gel), and oral metoclopramide 5 to 10 mg; (3) prophylaxis with a daily preventive medication such as propranolol or nadolol, amitriptyline, antiepileptic agents (eg, valproic acid, levetiracetam, topiramate), and others; (4) counseling and avoidance of triggering factors; and (5) biofeedback employing relaxation training and temperature feedback. For some children, analgesics and rest may be the only treatments that are necessary.
With regard to medication management, at full dose per weight, ibuprofen or acetaminophen are efficacious when given rapidly, ie, during a migraine aura or as soon after headache onset as possible. However, if the individual typically has severe headaches that are inadequately responsive to analgesics, then triptans are the next choice for treatment.
For severe headaches or migraine with aura, rapid treatment with a nasal or oral triptan is helpful for about 70% to 80% of headache episodes. Preceding the dose of a nasal triptan with a hard candy can ameliorate the side effect of bad taste. Based on the study of Linder and colleagues, the FDA in June 2009 approved oral almotriptan malate as the first triptan approved for use in adolescents aged 12 to 17 years old. The 25 mg dose showed a statistically significant decrease in headache at the 2-hour time point (Linder et al 2008). In March 2012, rizatriptan was FDA approved for the treatment of headaches in children ages 6 to 17 years (5 mg once for those less than 40 kg and 10 mg once for those more than 40 kg weight). In addition, reports have confirmed safe use of nasal triptans, acetaminophen, and ibuprofen for children as young as 4 years of age, and oral and subcutaneous triptans may be used for children as young as 6 years of age. Experience in children is limited for intravenous dihydroergotamine, but it seems to have the same safety profile as in adults. Triptans and dihydroergotamine should not be used for hemiplegic migraine or for children who have cardiac disease or hypertension. Opioids and barbiturate-combination medications are usually avoided in outpatient treatment of pediatric headaches.
Institution of preventive treatment is indicated if the above measures are ineffective or if the headaches are especially frequent (more than 2 to 3 per month). Other than limited evidence supporting the preventive use of topiramate and trazodone, pediatric migraine studies have not found effective preventive treatments, but this should not be interpreted as meaning there are no effective treatments (Arruda 2013). Propranolol or nadolol (beta blockers) can be given on a daily basis. For those weighing less than 30 kg, the dosage is 1 mg/kg per dose given 3 times daily. For those weighing more than 30 kg, nadolol is started at 40 or 80 mg as a single daily dose and increased every 2 weeks as limited by side effects such as fatigue, depression, or sleep disturbances. Special caution is necessary in those for whom beta blockade could cause problems, eg, asthmatics (it may worsen bronchospasm), allergic individuals receiving desensitization shots, children taking insulin (it can mask symptoms of anaphylaxis or hypoglycemia), or children with congestive heart failure or renal insufficiency. Other oral medications have been useful when administered daily: amitriptyline or nortriptyline starting at 10 mg, verapamil, cyproheptadine (4 mg tab) starting at one-half tab once or twice daily, antiepileptic agents (divalproex, topiramate, levetiracetam, and as used more in the past, phenobarbital and phenytoin), trazodone, and naproxen sodium. In a study using divalproex sodium ER, 500 mg/day for 15 days and then 1000 mg/day, the median rate of headaches decreased by 75% when comparing the first month of therapy to the fourth month. (However, the decrease in the mean rate was less than 50%.) Adverse effects were similar to those in adults (Apostol et al 2009). In a study of topiramate in adolescents, the 100 mg dose was superior to the 50 mg dose. Topiramate not only decreased headaches, but also decreased absenteeism, presenteeism (working while a headache is present), and loss of productivity (Lofland et al 2007; Lewis et al 2009). Oral chlorpromazine has not been studied for migraine in children but may be used intermittently at doses of 2.5 to 5 mg every hour for 4 to 5 doses until sleep or headache relief occurs. Oral melatonin, riboflavin, and coenzyme Q10 are not effective for the prophylactic treatment of pediatric migraine (Alstadhaug et al 2010; Bruijn et al 2010; Slater et al 2011).
Especially severe migraine attacks can be treated with oral prednisone (initially 2 mg/kg per day up to 60 mg per day) for a tapering 6 to 14 day course when other agents are unsuccessful or before instituting systemic therapy. For status migrainosus, consider intravenous or intramuscular administration of drugs such as valproate sodium (10 to 15 mg/kg), metoclopramide (5 to 10 mg) or prochlorperazine (2.5 to 5 mg) (Brousseau et al 2004). Metoclopramide or prochlorperazine can be followed 20 minutes later by intravenous dihydroergotamine with an initial dose of 0.5 to 1 mg. In general, dihydroergotamine should not be used within 24 hours of a triptan. Status migrainosus, frequently associated with prolonged vomiting, may require hospitalization employing intravenous rehydration and treatment with metoclopramide and dihydroergotamine as above, and then dihydroergotamine every 8 hours for several days. Morphine or intravenous chlorpromazine are sometimes added.
Additional aspects of counseling include the following: (1) reassurance that there is not a brain tumor or disease; (2) avoidance of triggering factors (especially stress, irregular or inadequate sleep, and irregular meal schedules); (3) the benign nature of migraine with regard to health; and (4) the importance of using analgesics early in the headache.
Advice regarding the benefits of adequate rest and relaxation can provide long-lasting benefit (Dooley and Bagnell 1995). Although stress is often an unavoidable part of life, sometimes stress can be reduced, eg, the child can more completely prepare for an upcoming examination, parents and children can be counseled regarding conflict resolution, and bullies can be avoided. The headache may be exacerbated by stress related to emotional or cognitive problems resulting from or causing school failure or child abuse. Addressing these problems may reduce the frequency of the headaches. Inadequate sleep might be due to obstructive sleep apnea among other possibilities.