Amy A. Gelfand, MD, MAS reviewing
Updated guidelines from the AAN focus on effective acute treatments, route of administration, and when to try an alternate medication.
Sponsoring Organization: American Academy of Neurology (AAN)
Background and Objective
The AAN has issued clinical practice guidelines, updated from those published in 2004 (Neurology 2004; 63:2215) on the acute treatment of migraine in children and adolescents, based on a systematic review. The review focused on self-administered treatments and thus does not cover emergency department or urgent care parenteral treatments for migraine in these age groups. (The AAN concurrently published guidelines on migraine preventive treatment; NEJM JW Neurol Nov 2019 and Neurology 2019; 93:500.)
- Ibuprofen (10 mg/kg) is recommended as an initial treatment in both children and adolescents. For adolescents, triptans (either alone or in combination with an NSAID) were also recommended, specifically: sumatriptan/naproxen tablets, sumatriptan or zolmitriptan nasal spray, rizatriptan oral dissolving tablets, and almotriptan tablets. If one triptan does not help, giving an alternate triptan is recommended.
- For patients with nausea, vomiting, or pain that becomes severe quickly, consider nonoral routes of administration. An antiemetic is also recommended for children and adolescents who have nausea.
- Counsel patients and families about avoidance of “medication overuse” (defined as ≥15 days per month for NSAIDs or acetaminophen and ≥10 days per month for triptans, opioids, or any combination of agents for ≥3 months). The guidelines also state, “There is no evidence to support the use of opioids in children with migraine.”
Oral triptan preparations are now recommended for adolescents.
The message is clear: NSAIDs and triptans are the mainstays of acute treatment of migraine in children and adolescents. Many of the treatment recommendations were inferred from adult data — a reasonable extrapolation, given that the pathophysiology of migraine is the same across the age spectrum (Continuum [Minneap Minn] 2018; 24:1108). In adults, we know: (1) treating when pain is still mild yields the best efficacy (Cephalalgia 2008; 28:383); (2) combining naproxen with sumatriptan is better than either alone (JAMA 2007; 297:1443); (3) treating during aura does not prevent or delay headache (Eur J Neurol 2004 Oct; 11:671; Neurology 1994; 44:1587); (4) taking a second triptan after 2 hours does not improve efficacy (even though triptan labeling might imply otherwise); however, (5) if headache is initially successfully treated and then recurs, a second dose can be useful (Cephalalgia 1994; 14:330); and (6) people who don’t respond to one triptan often respond to another (Cephalalgia 2003; 23:463).
The concept of medication-overuse headache is somewhat controversial. Observational data linking frequent acute medication use with higher headache frequency are, by necessity, confounded by indication (Neurology 2017; 89:1296). High-quality data on this topic are even scanter in children and adolescents. Until better data are available, clinicians could consider allowing patients to treat at the frequency that their migraine symptoms dictate while implementing other strategies to address high headache frequency.