American Academy of Neurology Issues Guidelines for Pediatric Migraine

Laurie Barclay, MD

December 27, 2004

Dec. 23, 2004 -- The American Academy of Neurology (AAN) has created a practice parameter for pharmacologic treatment and prevention of migraine in children. The new guidelines have been endorsed by the American Academy of Pediatrics and the American Headache Society, and they are published in the Dec. 28 issue of Neurology.

"As pediatric neurologists we are confident that the most common pharmacological headache treatments given to adults are also safe and effective for children," lead author Donald W. Lewis, MD, from the Children's Hospital of the King's Daughters in Norfolk, Virginia, says in a news release.

Based on a literature review of 166 articles describing pertinent placebo-controlled trials published during the last two decades, the guidelines state that ibuprofen and acetaminophen are safe, well tolerated, and effective for acute treatment of migraines in children and adolescents, and that sumatriptan nasal spray is safe and effective in adolescents.

However, none of the oral triptan medications were shown to be effective in these age groups. Rizatriptan and zolmitriptan were safe and well tolerated but were not superior to placebo.

Of 12 agents evaluated for preventive therapy, only flunarizine is probably effective, whereas pizotifen, nimodipine, and clonidine are probably ineffective. Data were insufficient for cyproheptadine, amitriptyline, divalproex sodium, topiramate, and levetiracetam; and data were conflicting for propranolol and trazodone.

"For children (greater than age 6 years), ibuprofen is effective and acetaminophen is probably effective and either can be considered for the acute treatment of migraine," the authors write. "For adolescents (greater than 12 years of age), sumatriptan nasal spray is effective and should be considered for the acute treatment of migraine. For preventive therapy, flunarizine is probably effective and can be considered, but is not available in the United States."

Migraine headaches are common in children, and incidence increases through adolescence, affecting about 8% to 23% of children aged 11 to 15 years. Average age of onset is 7.2 years for boys and 10.9 years for girls.

"For a clinical problem so prevalent in children and adolescents, there is a disappointing lack of evidence from controlled, randomized, and masked trials," the authors conclude. "The safety and efficacy of currently available medications used to treat migraine headaches in adults need to be established in children and adolescents, particularly the dose and age range in which these medications are deemed safe and effective to use. Failure of an agent for acute or preventive therapy to demonstrate efficacy to a statistically significant degree does not imply that these medications have no role in the pediatric population and their use must be based upon good clinical judgment."

Some of the authors report various financial arrangements with AstraZeneca, Ortho-McNeil, Merck, American Home Products, GlaxoSmithKline, Abbott Laboratories, Eli Lilly, MedPointe, Pfizer, UCB Pharma, Johnson & Johnson, Allergan, Metis, NPS, Pozen, X-Cel Pharmaceuticals, and/or Medtronic.

Neurology. 2004;63(12):2215-2224

Reviewed by Gary D. Vogin, MD

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