Note from the National Guideline Clearinghouse: This guideline references a drug(s) for which important revised regulatory information has been released.

Pediatric Migraine

Evaluation and Diagnosis

A thorough evaluation and physical history are essential to a correct diagnosis and ultimately to a successful treatment outcome. Non-headache-specific areas that should be covered during the patient interview include details of early childhood development, school function, past and present medical problems, past medication use for both headache and other disorders, and drug and alcohol use. Involving both the patients and the parents can be helpful when inquiring about anxiety, tension, and nervousness. Moreover, symptoms of depression should be explored, as should a family history of headaches or psychological or psychiatric disorders.

Next, practitioners should ask patients about their headaches. Rothner and Winner propose a format for asking headache-specific questions (see Table 10.1 of the original guideline document). A third set of questions, focused on symptoms of increased intracranial pressure or progressive neurologic disease including ataxia, lethargy, seizures, visual disturbances, focal weakness, personality change, and loss of intellectual abilities may be helpful.

Red flags that require further exploration for potential serious headache etiology include:

• Headache severity that has increased dramatically
• Headache that awakens the child from sleep
• A change in an established headache pattern

As is the case with adult migraine, pediatric migraine is a clinical diagnosis made because of specific symptoms in the absence of other explanations for these symptoms. In the past, the same criteria for the diagnosis of adult migraine with and without aura established by the International Headache Society (IHS) in 1988 have been used for the diagnosis of pediatric migraine. Despite the recent revisions in the International Headache Society criteria, the concerns on pediatric headaches were not addressed. More recently, a number of pediatric headache specialists have published studies suggesting that these criteria are too restrictive for diagnosing migraine in children. The table below reviews the proposed criteria, with changes from the adult criteria in bold type.

In addition, children may experience other specific syndromes that are felt to represent childhood migraine variants. These disorders have neurologic symptoms and signs often not accompanied by headache and thus require diagnostic testing, such as imaging and electroencephalogram (EEG), to rule out ischemic and epileptic events. The table below outlines these disorders and their differential diagnosis.

The differential diagnosis of typical migraine without aura is limited. Numerous studies have indicated that neuroimaging and electrodiagnostic testing are of little value. In migrainous headaches that occur out of sleep or that are present upon awakening, EEG may be of help in ruling out migraines associated with nocturnal epilepsy. Severe sinusitis and processes causing increased intracranial pressure may present with morning headaches associated with nausea and or vomiting.

The differential diagnosis of migraine with aura includes epilepsy and vascular lesions. Depending on the type of migraine aura encountered, sleep-deprived EEG and magnetic resonance imaging/angiography (MRI/MRA) may be helpful.

Nonpharmacologic Treatment

Treatment of migraine in children and adolescents should begin with the same general interventions that one would consider with adults, including regulating sleep, diet, and exercise. Stress management is also important but differs between children and adults. Children experience stress related to school as a chronic stressor as opposed to the episodic acute stressors experienced by adults. Children are also stressed by homework, extracurricular activities, and peer relationships. Awareness of these factors can lead to lifestyle changes that can improve headache. In addition to simple stress identification, children and adolescents over the age of 10 respond very well to formal stress-reduction techniques, such as biofeedback. Many children carry heavy backpacks that can cause muscle strain and spasm in neck and shoulder muscles. This can exacerbate headache and can be treated with physical modalities such as massage or physical therapy.

Acute Treatment

Treatment of an acute migraine attack should begin as soon as the child recognizes that he or she is experiencing a migraine. This may require educating the child, the parent, and the school about the benefits of early intervention. Written permission and prescriptions may be necessary for children to receive medication at school. It is also important to maintain a diary to review the response to interventions, as well as to demonstrate patterns not previously noticed.

Nonspecific therapies such as acetaminophen and ibuprofen may be considered as initial acute therapies, but they should not be continued if they are ineffective. Appropriate doses based on weight must be used. If there is a lack of response, migraine-specific therapies should be considered early in the treatment algorithm. There is a large body of evidence demonstrating the safety of triptans in adolescents over 12 years of age. Large multicenter trials have evaluated the safety and tolerability of sumatriptan tablets, sumatriptan nasal spray, rizatriptan tablets, and zolmitriptan tablets. These medications are very well tolerated among adolescents and have not been associated with serious adverse events. The same screening process for cardiovascular risks should be undertaken in children and adolescents as with adults in determining the appropriateness of triptan use. Table 10.4 of the original guideline document lists acute medications with dosage ranges for the medications that have undergone clinical trials for the acute treatment of migraine in children and adolescents. Each triptan treatment can be repeated in 1 to 2 hours if there is a partial response, with a maximum of 3 doses in 24 hours.

Rescue Treatment

Similar to adult therapy, it is important to include rescue medications for children and adolescents, as they may not have a complete response to acute treatment every time. A good rescue plan can often keep children out of the emergency room. Rescue medications can include antiemetics such as promethazine or metoclopramide along with a nonsteroidal anti-inflammatory drug (NSAID) if not used for acute therapy. These will help with nausea and vomiting, may work directly on migraine, and will cause drowsiness to induce sleep.

Prophylaxis

Prophylaxis should be considered for patients who consistently experience frequent migraines (at least 1 per week) or who experience migraines less frequently but also experience frequent, less severe headaches that may impair their activities and/or affect their quality of life. Patients should be included in the decision making about the need for prophylaxis and the type, determined on the basis of comorbid medical conditions and side effect profile. For example, competitive athletes and individuals with asthma should avoid beta-blockers, while patients with comorbid epilepsy may want to consider anticonvulsants as migraine prophylaxis.

Many agents that are found useful in adult migraine may also have a role in pediatric migraine. Generally, lower dosages are commenced and these dosages are titrated. Prophylactics can take 1 to 2 months before full efficacy is established, so adequate trials must be attempted. Table 10.5 of the original guideline document outlines the categories of commonly used preventive medications, possible dosing ranges, side effects, and contraindications.

The length of prophylactic treatment should be tailored to the patient. Avoiding discontinuation of preventives during the school year is advisable. Many patients are successfully tapered after 3 to 6 months of improved headache frequency. Patients do not have to be completely migraine-free to consider tapering. Abortive agents should nearly always be provided in addition to prophylactic agents, as the patient may still experience migraines, even on an effective preventive agent.

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