Pediatric Primary Headache From A to Z

William T. Basco, Jr., MD, MS


June 24, 2015

In This Article

Options for Headache Prevention

Headache experts consider prevention successful if the approach reduces the frequency or severity by 50%, reinforcing the need to manage patient and family expectations. Being "headache free" may not be a reasonable goal for most patients, hence the need to focus on the ability to function and not the numerical level of headache pain.

First-line drugs for prevention of migraine are propranolol and flunarizine. Flunarizine has a number needed to treat (NNT) of 1.75 to achieve a 50% reduction in headache frequency and duration, whereas propranolol has a NNT of 1.5.[15] However, flunarizine is not easily available in the United States, and propranolol has troublesome side effects.

Other options include topiramate, which has a good deal of evidence in children and a US Food and Drug Administration (FDA) indication for migraine prophylaxis in children aged 12-17 years. Dosage guidelines for topiramate are 0.5-2 mg/kg/day (1.5-2 mg is the most effective range), given at night to reduce side effects.[16]

Amitriptyline is also an option at 1-2 mg/kg/day, with a maximum dose of 60 mg.[17] Cyproheptadine has a role at a dose of 0.1 mg/kg; this may be the preferred drug for younger children, although it should be given at night to minimize side effects. In a review of 126 children who were prescribed either amitriptyline or cyproheptadine, Lewis and colleagues[18] demonstrated a positive response in 89% of children on amitriptyline and 83% of children on cyproheptadine after 6 months of treatment, with reductions in headache frequency > 55% for both.

Botulinum toxin (administered by injection) is effective and is FDA-approved in adults for chronic daily headache. Active clinical trials are evaluating its effectiveness in children.

Several vitamin and nutritional supplement options are available to treat pediatric headache and have been reviewed by Kemper and Breuner.[19] For headache in children, data support the effectiveness of magnesium, butterbur, coenzyme Q10, and vitamin D. Acupuncture can be effective in children and is supported by data, but is often not covered by insurance.

In summary, Dr Nelson reminded the audience that triple therapy with NSAIDs, antiemetics, and triptans was effective in the acute setting, with DHE reserved for hospitalized patients. Topiramate and amitriptyline appear to be the best prophylactic medications, on the basis of availability and pediatric data. However, the number of randomized controlled trials evaluating migraine prophylaxis is very low, suggesting an ongoing need for additional high-quality trials to evaluate headache prevention options.


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