Pediatric Migraine Guidelines Show Limits of Current Research

By Anne Harding

December 12, 2019

NEW YORK (Reuters Health) - New guidelines on pharmacological treatment for pediatric migraine underscore the need for more research to help the one-third of children and adolescents who aren't helped by existing treatments, according to the authors of a new report.

"For these children, we hope that the guidelines are seen as a call to action to continue and expand pediatric migraine research," Dr. Christina L. Szperka of the Children's Hospital of Philadelphia and colleagues conclude in their JAMA Network Clinical Guideline Synopsis, published in JAMA Neurology.

The American Academy of Neurology (AAN) and the American Headache Society (AHS) released their guidelines on acute and preventive pharmacologic treatment for children and adolescents with migraine this August, updating a 2004 guideline.

The AAN/AHS guidelines recommend ibuprofen for children and adolescents for acute treatment of pain, and state that sumatriptan/naproxen oral, zolmitriptan nasal, sumatriptan nasal, rizatriptan oral, or almotriptan oral should be considered for adolescents.

They also recommend advising families on lifestyle, migraine triggers and avoiding acute medication overuse, and note that many preventive medications have not been shown to be better than placebo.

"According to the guidelines, the strongest evidence for migraine prevention in children/adolescents is for topiramate (labeled as an anti-seizure medication), propranolol (labeled as a blood-pressure medicine), and the combination of amitriptyline (labeled as an anti-depressant medication) and cognitive-behavioral therapy together," Dr. Szperka told Reuters Health by email.

"There are additional pharmaceutical preventives which we find helpful in clinical practice, but did not demonstrate efficacy over placebo in clinical trials in children," she added. "Some of this is related to clinical trial details (who was included, design of the trial, high rate of response in placebo-treated groups, etc), so in reality we use a broader list of treatments, not just the ones listed here."

She added: "All migraine patients should be instructed to use an acute treatment to reduce the pain and disability from individual attacks. The guidelines recommend both non-steroidal anti-inflammatory medications (ibuprofen), and triptan medications. Several triptans have been FDA (Food and Drug Administration)-approved for adolescents, and rizatriptan has been FDA-approved for children 6 years and older."

The new guidelines did not address nonpharmacological or nutraceutical treatments, Dr. Szperka and her team point out.

"In thinking about ways to decrease the frequency of migraines, we often begin with behavioral factors," the researcher said. "Moving forward, it would be helpful to test out which components really matter."

Several nutraceuticals have been investigated for preventing pediatric migraine, including vitamin D, magnesium, vitamin B2, coenzyme Q10, and polyunsaturated fatty acids, she added.

"These treatments are used very commonly because they cause few side effects (though they are not regulated), so we wish that the guidelines had reviewed the relevant studies," Dr. Szperka said. "However, most of the studies have been observational studies, or small trials, so more work is needed."

SOURCE: JAMA Neurology, online December 9, 2019.