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Pediatric Migraine: Clinical Pearls in Diagnosis and Therapy: Page 3 of 4

Pediatric Migraine: Clinical Pearls in Diagnosis and Therapy: Page 3 of 4

PHARMACOTHERAPY

Reserve preventive and acute medications for patients with frequent and disabling headaches. Acute intervention should begin within 30 minutes; pediatric migraines rapidly reach peak pain intensity within 4 hours and then usually resolve. Medications should be available and accessible both at school and at home. School health services need to be aware of a patient's diagnosis and of the need to rapidly administer the proper medication.

Acute medications. Acute migraine therapies can be classified as migraine-specific or migraine nonspecific (Table 4). Although both types of therapies are effective in pediatric patients, some patients fail to achieve a pain-free state within 2 hours of taking an over-the-counter analgesic. Nevertheless, therapeutic trials of simple analgesics are warranted as first-line acute migraine therapy in treatment-naive pediatric patients. Be on guard for medication overuse headache (MOH).

Analgesics and MOH. Ibuprofen in doses of 7.5 to 10 mg/kg is effective for acute migraine.3 However, using simple analgesics more than twice weekly can lead to MOH.15 Up to 30% of children with chronic daily headache have been shown to use analgesics daily.16

MOH can occur at any age, even in children as young as 2 years. A headache pattern may represent MOH if it typically occurs 15 days or more per month for more than 3 successive months in a patient who frequently uses a simple analgesic. MOH worsens as the patient accelerates analgesic use. Adolescents may complain that the headache awakens them from sleep and is present when they wake up. Immediately on sensing the return of the headache, the patient will take another analgesic or be given additional medication by a parent. Over time, the patient rarely experiences a pain-free interval. Intermittent severe, disabling migraines develop into mild to moderate daily headache.

When analgesics are abruptly discontinued, the headache pattern intensifies once again. However, successful discontinuation of analgesics results in an 80% reduction in headache frequency in most patients.17 As in adults, MOH is associated with the use of simple analgesics; combination drugs that contain butalbital and caffeine; and triptans, opioids, and ergotamines.

Triptans. Several large multicenter double-blind, placebo-controlled trials have shown that triptans are safe and well tolerated in children aged 12 years and older.8 Unfortunately, because of trial design flaws, placebo response rates are high in pediatric migraine studies, which limits our ability to determine the true effectiveness of oral triptans. Open-label trial evidence supports the effectiveness of oral zolmitriptan and subcutaneous sumatriptan in patients 12 to 17 years old.18 Unlike oral sumatriptan, the nasal spray formulation has been found to be safe and effective in acute adolescent migraine.19 Although not approved for use in patients younger than 18 years, triptans should be considered first-line therapy for acute treatment of disabling migraines that are unresponsive to simple analgesics.

A MANAGEMENT GAME PLAN

Always make certain that each patient and his or her family members are completely in agreement on the "game plan" for preventing migraines--as well as how acute medications should be administered. Adherence to the following suggestions improves the overall success of acute migraine management:

•Early intervention (within 30 minutes); this most often results in resolution of pain within 2 hours and less chance of headache recurrence.

•Avoid the frequent use of "backup" or rescue medications.

•Practice and adhere to the lifestyle intervention strategies to reduce neurologic sensitivity.

If you are concerned about possible adverse events associated with triptan use in young children, consider giving the initial dose in the office setting under observation--regardless of whether the patient is symptomatic. Patients who use nasal spray or injections should also practice how to properly use the drugs in the office setting before self-treating their first migraine.

The effectiveness, tolerability, and safety of acute migraine therapy can be evaluated with the help of a headache diary. Patients or their parents are asked to record the date and time of the attack, the trigger, the location of pain, symptoms, severity (on a 10-point severity scale), medication (name, formulation, and dose), time the medication was taken, and the quality of relief (none, moderate, complete) achieved after 2 and 4 hours. Encourage patients or parents to record any other notes about each headache episode that they feel are important to bring to your attention.

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