How Can Neurologists Manage Pediatric Migraine?

Forty percent of pediatric and adolescent patients with migraine do not get better following first-line treatment.

Neurology Reviews. 2017 March;25(3):29

March 2, 2017|Neurology Reviews

OJAI, CA—Migraine headaches can be debilitating in children and adolescents and result in more missed days of school and poorer performance in the classroom, compared with children without migraine, according to an overview presented at the 10th Annual Winter Conference of the Headache Cooperative of the Pacific.

“The estimate is that 130,000 school days are missed every two weeks due to pediatric migraine…. It is really a remarkable amount of disability coming from migraine in kids,” said Amy Gelfand, MD, Assistant Professor of Clinical Neurology and Pediatrics at the University of California, San Francisco School of Medicine. Taking a proper headache history and helping children maintain a regular lifestyle that includes regular sleep and exercise, as well as adequate water intake, in addition to providing optimal acute treatments that are well tolerated, are key components to managing pediatric migraine.

Understanding Pediatric Migraine

Pediatric migraine is defined as at least five attacks that fulfill the following criteria: headache attack lasting for two to 72 hours (untreated or unsuccessfully treated), headache with at least two of four characteristics (ie, unilateral location [though in children it is often bilateral], pulsating quality, moderate or severe intensity, and aggravation by or causing avoidance of routine physical activity), and headache accompanied by either nausea and vomiting or phonophobia and photophobia. It affects approximately 5% of children by age 10, making migraine five to 10 times more common than epilepsy in children. Chronic migraine, which entails headache on at least 15 days per month for at least three months, affects 0.6% of children between ages 5 and 12.

Pediatric migraine can have a different phenotype than adult migraine. The shortest duration for untreated or unsuccessfully treated attacks in adults is four hours, compared with two hours in children. In addition, migraines in children and adolescents tend to be bilateral.

Following puberty, there is a higher prevalence of migraine among young women and girls than among boys and young men, said Dr. Gelfand. Also, children with low socioeconomic status are nearly fourfold more likely to have chronic migraine than children from affluent backgrounds.

How to Take a Pediatric Headache History

A systematic approach to taking a headache history can be helpful, said Dr. Gelfand. When neurologists take a headache history, seating the child or adolescent in a central position near the clinican can help signal that the patient is going to be the primary person to provide the history. In addition, neurologists should set expectations for pediatric patients by explaining the questions they are going to ask about the child’s headaches.

Children are encouraged to share additional information about their headaches and to ask parents for help when necessary. Also, neurologists should hesitate to consider “not really” an answer to questions about the presence of symptoms such as nausea or movement sensitivity, because it often means “yes, but it is mild, and I can handle it and do not want to complain.”

Finally, when querying for sensitivity to light or sound, neurologists are advised to ask the following questions: During your headaches, do lights ever bother you? Do lights ever seem brighter than usual? Do lights ever make the headache worse? “For younger kids who might not be able to articulate sensitivity to light or sensitivity to sound, we may be able to infer those sensitivity symptoms from their behavior. Are they pulling the blankets up over their head or are they asking for the TV to be turned off? These are behaviors that their caregivers can report,” said Dr. Gelfand.

Acute Migraine Treatment

Acetaminophen and ibuprofen have been examined in randomized controlled trials that included children as young as 4. These drugs appear to be efficacious. In addition, the FDA has approved four triptans for acute treatment of pediatric migraine. Almotriptan was approved in 2009 for adolescents ages 12 to 17. In 2012, the FDA approved rizatriptan for children and adolescents ages 6 to 17. Finally, in 2015, zolmitriptan, a nasal spray, was approved for adolescents ages 12 to 17, as was a combination including naproxen and sumatriptan. Children with a history of peripheral vascular disease, stroke, and uncontrolled hypertension should not use triptans for the treatment of pediatric migraine.

In addition, Powers et al observed that amitriptyline and topiramate were no different from placebo for reducing headache frequency; approximately 60% of participants in all three study arms improved. The 361 children and adolescents involved in the study received a lot of headache education and counseling about medication overuse, and also received optimally dosed acute migraine medications, which may have contributed to the high rate of excellent outcomes, said Dr. Gelfand.