Pharmacologicaltreatment of migraine headache in

children and adolescentsA REVIEW

What is Childhood Migraine ?

• Migraine is the most common acute and recurrent headache syndrome in children

• Migraine without aura is a recurrent headache disorder characterized by attacks lasting 2 to 72 hours in children . Typical features include a unilateral headache of moderate to severe intensity with a pulsating quality of pain that is associated with nausea, photophobia, or phonophobia and is aggravated with routine physical activity

INCIDENCE : WORLDWIDE• Migraine headaches are common in children and occur with increasing frequency through adolescence.

• The reported prevalence increases with age : 3% ( age 3 to 7 years )

4 to 11% ( age 7 to 11 ) 8 to 23% ( age 11 to 15 )

• Mean age at onset being 7.2 years for boys and 10.9 years for girls.

• Migraine affects males and females equally at a young age (<14y), and more females than males in adolescence and young adulthood.

INCIDENCE :INDIA

• Study done among children aged 11 to 15 years• Sample size of 2000 ( 1000 boys and 1000 girls )• Study design : Self administered questionnaire to subjects and parents• Prevalance of recurrent Headache : 18 % boys

21 % girls• Prevelance of migraine headache : 9 % boys 14 % girls

Indian Pediatrics. 2003 Jul;40(7):665-9.Prevalence and characteristics of migraine among adolescents: a questionnaire survey.Shivpuri D, Rajesh MS, Jain D.

Approach to a child with Headache

Headache disability assessment : PaedMIDAS / PedsQL

The PedsQL  Measurement Model is a modular approach to measuring health-related quality of life (HRQOL) in healthy children and adolescents and those with acute and chronic health conditions. The PedsQL  Measurement Model integrates seamlessly both generic core scales and disease-specific modules into one measurement system.

ViewPaedMIDAS

International Headache Society classification of headache disorders: Criteria for pediatric migraine without aura

A. 5 attacks fulfilling features B–D

B. Headache attack lasting 1 to 72 hours

C. Headache has at least 2 of the following 4 features:1. Either bilateral or unilateral (frontal/temporal) location2. Pulsating quality3. Moderate to severe intensity4. Aggravated by routine physical activitiesD. At least 1 of the following accompanies headache :1. Nausea and/or vomiting2. Photophobia and phonophobia ( may be inferred from their behaviour )

Types of migraine :• Migraine without Aura

- Menstrual Migraine• Migraine with Aura• Hemiplegic migraine• Retinal Migraine• Syndromes associated with migraine

- Cyclical vomiting syndrome- Abdominal migraine- Benign paroxysmal vertigo- Benign paroxysmal torticollis

• Chronic Migraine• Migraine Variants

- Alice in wonderland syndrome- Confusional migraine- Ophthalmoplegic migraine

Objective:

To review evidence on the pharmacologic treatment of the child with migraine headache.

MethodologyThree organizations participated in the development of this practice parameter, including the American Academy of Neurology (AAN), the Child Neurology Society, and the American Headache Society. The American Academy of Pediatrics reviewed the manuscript.

INCLUSION CRITERIA• The age qualifier of 3 years to 18 years was selected• Only those articles reporting studies with 10 patients or more were included. • 166 articles and abstracts were identified and reviewed for preparation of this parameter. Articles published from 1980 through December 2003 were included. Databases searched included Medline and CurrentContents.

Parameters used :• Number of patients,• Age, • Sex, • Nature of subject selection,• Case-finding methods,• Inclusion and exclusion criteria, • Headache type and characteristics,• Study design and statistical analysis employed.

Depending on the strength of this evidence it was decided whether specific recommendations could be made, and if so, the strength of these recommendations.

Treatment options include use of

1) acute or episodic medications2) prophylactic or preventive agents3) nonpharmacologic or biobehavioral interventions.

Treatment :

Drugs for Acute management of Migraine in childrenParameters used for effective treatment include :• Reduction in pain score• 2 hour post therapy alleviation of headache• Relief of associated symptoms• Need for rescue medications

Drugs studied for this purpose:IbuprofenAcetaminophenTriptans

Recommendations for the acute treatment of migrainein children and adolescents.

• Ibuprofen is effective and should be considered for the acute treatment of migraine in children (Level A).• Acetaminophen is probably effective and should be considered for the acute treatment of migraine in children (Level B).• Sumatriptan nasal spray is effective and should be considered for the acute treatment of migraine in adolescents (Level A).• There are no data to support or refute use of any oral triptan preparations in children or adolescents (Level U).• There are inadequate data to make a judgment on the efficacy of subcutaneous sumatriptan (Level U).

Preventive treatments :

General principles related to the goals of migraine preventive therapies :

1) reduce attack frequency, severity, and duration2) improve responsiveness to treatment of acute attacks3) improve function, reduce disability, and improve the patient’s quality of life.

The following questions are addressed in the reviewof medications listed below:

1) What are the effects on the frequency and/or severity of migraine attacks of medications taken on a daily basis for prevention of migraine?

2) How safe and tolerable are preventive migraine medications in children and adolescents?

3) How do the efficacy and tolerability of preventive medications for migraine compare to those for placebo?

Medications studied for preventive treatment of Migraine :

• Cyproheptadine (histamine and serotonin antagonist with anticholinergic and calcium channel blocking properties )• Propranalol ( beta blocker )• Clonidine ( alpha adrenergic agonist )• Amitryptiline ( TCA )• Trazodone ( Triazolopyridine derivative )• Divalproex Sodium ( Valproate )• Topiramate• Levitiracetam • Nimodipine • Flunarezine Calcium Channel BLocker

Recommendations for preventive therapy of migraine in children and adolescents.

1. Flunarizine is probably effective for preventive therapy and can be considered for this purpose .

2. There is insufficient evidence to make any recommendations concerning the use of cyproheptadine, amitriptyline, divalproex sodium, topiramate, or levetiracetam.

3. Recommendations cannot be made concerning propranolol or trazodone for preventive therapy as the evidence is conflicting.

4. Pizotifen and nimodipine (Level B) and clonidine (Level B) did not

show efficacy and are not recommended.

Behavioral interventions — Cognitive-behavioral therapy, including biofeedback training and relaxation techniques, may be beneficial in reducing headache symptoms, as illustrated by the following observations:

●A controlled trial randomly assigned 135 children and adolescents (ages 10 to 17 years) with chronic migraine to treatment with either cognitive-behavioral therapy (CBT) or headache education; both groups also received amitriptyline.At 20 weeks, a significantly greater proportion of subjects in the CBT plus amitriptyline group compared with those in the headache education plus amitriptyline group achieved a ≥50 percent reduction in days with headache .In addition, a reduction in headache disability to mild or none was significantly greater with CBT.

● In a trial in Germany, 43 children with migraine were assigned randomly to stress management training with either progressive relaxation or cephalic vasomotor feedback for six weeks or to treatment with metoprolol(a beta-blocker) for 10 weeks . Reduction in the headache index (a measure of frequency and intensity of headache episodes) was greatest with relaxation and stress management training, next with cephalic vasomotor feedback and stress management training, and least with metoprolol. Clinical improvement persisted through follow-up at eight months

1. Neurology December 28, 2004 vol. 63 no. 12 2215-2224; Practice Parameter : Report of the American Academy of Neurology Quality Standards Subcommittee and the Practice Committee of the Child Neurology Society D. Lewis, MD; S. Ashwal, MD; A. Hershey, MD; D. Hirtz, MD; M. Yonker, MD; and S. Silberstein, MD

2. Developmental Medicine & Child Neurology 2010, 52: 1088–1097; Prevalence of headache and migraine in children and adolescents: a systematic review of population-based studies Ishaq Abu-Arafeh, Sheik Razak, Baskaran Sivraman , Catriona Graham

3. J Am Osteopath Assoc April 1, 2005 vol. 105 no. 4 suppl 2S-8S; Pediatric Migraine: Recognition and Treatment Andrew D.

Hershey, MD, PhD Paul K. Winner, DO

References :