Migraine in children, Childhood migraine, Headache syndromes in children, managing a child with headache

1. Pharmacological
treatment of migraine headache in
children and adolescents
A REVIEW

2. What is Childhood Migraine ?
• Migraine is the most common acute and
recurrent headache syndrome in children
• Migraine without aura is a recurrent headache
disorder characterized by attacks lasting 2 to 72
hours in children . Typical features include a
unilateral headache of moderate to severe
intensity with a pulsating quality of pain that is
associated with nausea, photophobia, or
phonophobia and is aggravated with routine
physical activity

3. INCIDENCE : WORLDWIDE
• Migraine headaches are common in children and occur
with increasing frequency through adolescence.
• The reported prevalence increases with age :
3% ( age 3 to 7 years )
4 to 11% ( age 7 to 11 )
8 to 23% ( age 11 to 15 )
• Mean age at onset being 7.2 years
for boys and 10.9 years for girls.
• Migraine affects males and females equally at a young
age (<14y), and more females than males in adolescence
and young adulthood.

4. INCIDENCE :INDIA
• Study done among children aged 11 to 15 years
• Sample size of 2000 ( 1000 boys and 1000 girls )
• Study design : Self administered questionnaire to
subjects and parents
• Prevalance of recurrent Headache : 18 % boys
21 % girls
• Prevelance of migraine headache : 9 % boys
14 % girls
Indian Pediatrics. 2003 Jul;40(7):665-9.
Prevalence and characteristics of migraine among adolescents: a questionnaire survey.
Shivpuri D, Rajesh MS, Jain D.

5. Approach to a child with Headache

6. Headache disability assessment :
PaedMIDAS / PedsQL
The PedsQL Measurement Model is a modular approach to
measuring health-related quality of life (HRQOL) in healthy
children and adolescents and those with acute and chronic
health conditions. The PedsQL Measurement Model
integrates seamlessly both generic core scales and disease-
specific modules into one measurement system.
ViewPaedMIDAS

7. International Headache Society classification of headache
disorders: Criteria for pediatric migraine without aura
A. 5 attacks fulfilling features B–D
B. Headache attack lasting 1 to 72 hours
C. Headache has at least 2 of the following 4 features:
1. Either bilateral or unilateral (frontal/temporal) location
2. Pulsating quality
3. Moderate to severe intensity
4. Aggravated by routine physical activities
D. At least 1 of the following accompanies headache :
1. Nausea and/or vomiting
2. Photophobia and phonophobia ( may be inferred from their
behaviour )

8. Types of migraine :
• Migraine without Aura
- Menstrual Migraine
• Migraine with Aura
• Hemiplegic migraine
• Retinal Migraine
• Syndromes associated with migraine
- Cyclical vomiting syndrome
- Abdominal migraine
- Benign paroxysmal vertigo
- Benign paroxysmal torticollis
• Chronic Migraine
• Migraine Variants
-Alice in wonderland syndrome
- Confusional migraine
-Ophthalmoplegic migraine

9. Objective:
To review evidence on the pharmacologic
treatment of the child with migraine
headache.

10. Methodology
Three organizations participated in the development of this practice
parameter, including the American Academy of Neurology (AAN), the
Child Neurology Society, and the American Headache Society. The
American Academy of Pediatrics reviewed the manuscript.
INCLUSION CRITERIA
• The age qualifier of 3 years to 18 years was selected
• Only those articles reporting studies with 10 patients or
more were included.
• 166 articles and abstracts were identified and reviewed
for preparation of this parameter. Articles published
from 1980 through December 2003 were included.
Databases searched included Medline and
CurrentContents.

11. Parameters used :
• Number of patients,
• Age,
• Sex,
• Nature of subject selection,
• Case-finding methods,
• Inclusion and exclusion criteria,
• Headache type and characteristics,
• Study design and statistical analysis employed.
Depending on the strength of this evidence it was decided
whether specific recommendations could be made, and if
so, the strength of these recommendations.

13. Treatment options include use of
1) acute or episodic medications
2) prophylactic or preventive agents
3) nonpharmacologic or biobehavioral interventions.
Treatment :

14. Drugs for Acute management of Migraine in children
Parameters used for effective treatment include :
• Reduction in pain score
• 2 hour post therapy alleviation of headache
• Relief of associated symptoms
• Need for rescue medications
Drugs studied for this purpose:
Ibuprofen
Acetaminophen
Triptans

16. Recommendations for the acute treatment of migraine
in children and adolescents.
• Ibuprofen is effective and should be considered for the
acute treatment of migraine in children (Level A).
• Acetaminophen is probably effective and should be
considered for the acute treatment of migraine in children
(Level B).
• Sumatriptan nasal spray is effective and should be
considered for the acute treatment of migraine in
adolescents (Level A).
• There are no data to support or refute use of any oral
triptan preparations in children or adolescents (Level U).
• There are inadequate data to make a judgment on the
efficacy of subcutaneous sumatriptan (Level U).

17. Preventive treatments :
General principles related to the goals of migraine
preventive therapies :
1) reduce attack frequency, severity, and duration
2) improve responsiveness to treatment of acute attacks
3) improve function, reduce disability, and improve the
patient’s quality of life.

18. The following questions are addressed in the review
of medications listed below:
1) What are the effects on the frequency and/or severity
of migraine attacks of medications taken on a daily
basis for prevention of migraine?
2) How safe and tolerable are preventive migraine
medications in children and adolescents?
3) How do the efficacy and tolerability of
preventive medications for migraine compare to
those for placebo?

19. Medications studied for preventive treatment of Migraine :
• Cyproheptadine
(histamine and serotonin antagonist with anticholinergic
and calcium channel blocking properties )
• Propranalol ( beta blocker )
• Clonidine ( alpha adrenergic agonist )
• Amitryptiline ( TCA )
• Trazodone ( Triazolopyridine derivative )
• Divalproex Sodium ( Valproate )
• Topiramate
• Levitiracetam
• Nimodipine
• Flunarezine
Calcium Channel BLocker

21. Recommendations for preventive therapy of migraine in children
and adolescents.
1. Flunarizine is probably effective for preventive therapy and can
be considered for this purpose .
2. There is insufficient evidence to make any recommendations
concerning the use of cyproheptadine, amitriptyline, divalproex
sodium, topiramate, or levetiracetam.
3. Recommendations cannot be made concerning propranolol or
trazodone for preventive therapy as the evidence is conflicting.
4. Pizotifen and nimodipine (Level B) and clonidine (Level B) did not
show efficacy and are not recommended.

22. Behavioral interventions — Cognitive-behavioral therapy,
including biofeedback training and relaxation techniques, may be
beneficial in reducing headache symptoms, as illustrated by the
following observations:
●A controlled trial randomly assigned 135 children and adolescents
(ages 10 to 17 years) with chronic migraine to treatment with either
cognitive-behavioral therapy (CBT) or headache education; both
groups also received amitriptyline.At 20 weeks, a significantly greater
proportion of subjects in the CBT plus amitriptyline group compared
with those in the headache education plus amitriptyline group
achieved a ≥50 percent reduction in days with headache .In addition, a
reduction in headache disability to mild or none was significantly
greater with CBT.

23. ● In a trial in Germany, 43 children with migraine were
assigned randomly to stress management training with
either progressive relaxation or cephalic vasomotor
feedback for six weeks or to treatment with metoprolol(a
beta-blocker) for 10 weeks . Reduction in the headache
index (a measure of frequency and intensity of headache
episodes) was greatest with relaxation and stress
management training, next with cephalic vasomotor
feedback and stress management training, and least with
metoprolol. Clinical improvement persisted through
follow-up at eight months

24. 1. Neurology December 28, 2004 vol. 63 no. 12 2215-2224; Practice
Parameter : Report of the American Academy of Neurology
Quality Standards Subcommittee and the Practice Committee of
the Child Neurology Society D. Lewis, MD; S. Ashwal, MD; A.
Hershey, MD; D. Hirtz, MD; M. Yonker, MD; and S. Silberstein, MD
2. Developmental Medicine & Child Neurology 2010, 52: 1088–1097;
Prevalence of headache and migraine in children and adolescents:
a systematic review of population-based studies Ishaq Abu-
Arafeh, Sheik Razak, Baskaran Sivraman , Catriona Graham
3. J Am Osteopath Assoc April 1, 2005 vol. 105 no. 4 suppl 2S-8S;
Pediatric Migraine: Recognition and Treatment Andrew D.
Hershey, MD, PhD Paul K. Winner, DO
References :