Recommendations on the Use of Anti-CGRP Monoclonal Antibodies in Children and Adolescents

Christina L. Szperka, MD, MSCE; Juliana VanderPluym, MD; Serena L. Orr, MD, MSc; Christopher B. Oakley, MD; William Qubty, MD; Irene Patniyot, MD; Ana Marissa Lagman-Bartolome, MD; Cynthia Morris, MD; Jessica Gautreaux, MD; M. Cristina Victorio, MD; Suzanne Hagler, MD; Sona Narula, MD; Meghan S. Candee, MD, MS; Catalina Cleves-Bayon, MD; Rashmi Rao, MD; Robert H. Fryer, MD, PhD; Alma R. Bicknese, MD; Marcy Yonker, MD; Andrew D. Hershey, MD, PhD; Scott W. Powers, PhD; Peter J. Goadsby, MBBS; Amy A. Gelfand, MD


Headache. 2018;58(10):1658-1669. 

In This Article

Abstract and Introduction


Migraine is common in children and adolescents and can have long-term consequences on educational performance, self-esteem, and cognitive well-being.[1,2] However, effective, well-tolerated, evidence-based therapies for migraine prevention in children and adolescents remain limited.[3]

In adults, monoclonal antibodies (mAbs) to calcitonin gene-related peptide (CGRP), or its receptor, have been shown to be efficacious for migraine prevention,[4–11] and in episodic cluster headache.[12] Although CGRP is expressed in multiple body systems,[13] trials to date have demonstrated minimal adverse events. The most commonly seen adverse events in adult trials included: injection site reactions, upper respiratory symptoms, and constipation. These treatments avoid the need for daily pill taking, and thus may improve adherence, which is known to be low with oral migraine preventives.[14]

Pediatric and adolescent migraine prevention trials will follow; however, outcome data from these will likely not be available for several years. In the interim, the decision regarding whether to treat pediatric patients with anti-CGRP mAbs will require providers to balance the potential for unknown risks against the potential benefits of the therapy. To bridge the gap until empiric data become available, this manuscript, written by members of the Pediatric and Adolescent Headache special interest group of the American Headache Society, is meant to serve as expert opinion (ie, class IV evidence) on the use of these antibodies in children and adolescents. This topic was discussed at the Pediatric and Adolescent Headache special interest group (SIG) meeting at the 2018 Annual Scientific Meeting of the American Headache Society, and via email communication to SIG members. Interested members volunteered to collaborate as co-authors on this document. Authors were divided into subgroups to draft the various sections of the manuscript. Recommendations were reached by consensus first within the subgroups and then all co-authors had the opportunity to read the entire manuscript so that final recommendations could be reached by consensus. The opinions expressed in this manuscript represent those of the co-authors and do not represent the opinion of the American Headache Society.