Pharmacologic Acute and Preventive Treatment for Migraine in Children and Adolescents

GUIDELINE TITLES Acute Treatment of Migraine in Children and Adolescents1 and Pharmacologic Treatment for Pediatric Migraine Prevention2 RELEASE DATE August 14, 2019 PRIOR VERSION Practice Parameter: Pharmacologic Treatment of Migraine Headache in Children and Adolescents from American Academy of Neurology (AAN) and Child Neurology Society, 2004 DEVELOPERS AAN and American Headache Society FUNDING SOURCE AAN TARGET POPULATION Children and adolescents with migraine MAJOR RECOMMENDATIONS AND RATINGS Acute Guidelines - Take a detailed history and make a specific headache diagnosis (Level of obligation to the recommendation, B). - Counsel patients to treat acute migraine early in the attack (B). - Use ibuprofen to treat pain in children/adolescents; in adolescents, consider sumatriptan/naproxen oral, zolmitriptan nasal, sumatriptan nasal, rizatriptan oral, or almotriptan oral (B). - If 1 triptan is ineffective, try another or a nonsteroidal anti-inflammatory drug-triptan combination (B). If headache pain spikes, quickly try a nonoral triptan (C). If there is nausea/vomiting, try non-oral triptan or add antiemetic (B-C). - Avoid triptans in patients with cardiovascular disease and accessory conduction pathway disorders (A). Patients with migraine with auramay use triptans (B). Preventative Guidelines - Advise patients and families on lifestyle factors, migraine triggers, and avoidance of acute medication overuse (B). - Consider preventive treatments in children/adolescents with frequent or disabling headaches or medication overuse (B). - Discuss with patients/families whether to use a preventive medication because placebo was as effective as the studied medication in many trials (B). - Discuss the evidence for and adverse effects of amitriptyline combined with cognitive behavioral therapy, topiramate, and propranolol for migraine prevention (B). When relevant, discuss teratogenic effects of topiramate and valproate and advise patients to use effective birth control methods and take folate (A). - Divalproex, onabotulinumtoxin A, amitriptyline alone, nimodipine, and flunarizine are not clearly better than placebo (insufficient evidence). - Continue to monitor the effectiveness of preventive treatments over time (A-B).