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Early treatment for acute migraine in children and teens is encouraged, but most preventive migraine medications are not better than placebo for pediatric patients, according to new guidance published in Neurology.

Two guideline documents, which offer evidence-based recommendations for and for children and adolescents, were issued by the American Academy of Neurology (AAN) and the American Headache Society (AHS), and were endorsed by the American Academy of Pediatrics and the Child Neurology Society. They update the 2004 AAN guideline on drug treatment of migraine in children and teens.

"We reviewed all of the available evidence, and the good news is that there are evidence-based treatments for children and teens that are effective for treating migraine attacks when they occur," guideline lead author Maryam Oskoui, MD, MSc, of McGill University in Montreal, Canada, said in a statement.

"However, most medications that are designed to prevent recurrent migraine attacks are only as good as placebo when used in children and there is little evidence to guide treatment of related symptoms such as nausea and sensitivity to light," she continued. "It should be noted that these medications, as well as placebo, were effective in more than 50% of the patients."

Notably, the evidence review stopped with studies published in 2017. As a result, the guidelines did not address treatments that became available more recently, including calcitonin gene-related peptide (CGRP) pathway inhibitors or neuromodulation devices. In addition, "the benefit of cognitive behavioral therapy, alone or in combination with other treatments in migraine prevention, warrants further study," Oskoui said.

Migraine is common in children and adolescents: its varies from 1% to 3% at ages 3 to 7, 4% to 11% at ages 7 to 11, and 8% to 23% by age 15. Migraine may co-occur with mood disorders such as depression and anxiety that can worsen disability and delay recovery.

The new AAN/AHS guidelines recommend children and teens have a detailed history and neurological examination, and patients and parents receive counseling about lifestyle factors that may affect headache frequency, including lack of physical activity, excess weight, excessive caffeine intake, poor sleep habits, and dehydration.

To prepare the guidelines, two subcommittees reviewed literature published from December 2003 to August 2017. The acute treatment guidance subcommittee emphasized the importance of early treatment and reported:

• Evidence to support the efficacy of using ibuprofen, acetaminophen (in children and adolescents), and triptans (in adolescents) for the relief of migraine pain, although confidence in the evidence varied between agents
• High confidence that adolescents who received oral sumatriptan/naproxen and zolmitriptan (Zomig) nasal spray were more likely to be headache-free at 2 hours than those receiving placebo
• No effective acute treatments for migraine-related nausea or vomiting in pediatric patients, but some triptans were effective for phonophobia and photophobia

The prevention guideline subcommittee assessed 15 Class I–III studies and determined:

• There was insufficient evidence to determine whether children and adolescents receiving divalproex (Depakote), onabotulinumtoxinA (Botox), amitriptyline, nimodipine (Nimotop), or flunarizine were more or less likely to have reduced headache frequency than those receiving placebo
• Pediatric patients receiving propranolol were possibly more likely than those receiving placebo to have an at least 50% reduction in headache frequency
• Children and adolescents receiving topiramate (Topamax) and cinnarizine were probably more likely than placebo recipients to have a decrease in headache frequency
• Combining cognitive behavioral therapy and amitriptyline was more beneficial than amitriptyline and headache education in reducing migraine attack frequency and migraine-related disability for children ages 10 to 17

"Although topiramate is the only FDA-approved medication for migraine prevention (in children and adolescents aged 12–17 years), the current evidence base raises some doubts about whether this treatment achieves clinically meaningful outcomes beyond those obtained by placebo," the guideline authors wrote. "There is insufficient evidence to confidently recommend this as a known efficacious preventive intervention."

Most children benefit from acute migraine treatments and lifestyle changes and do not require additional preventive treatment, they noted.

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