II. General
- See Headache General Measures
- Keep Headache diary
- Keep medication available at all times (school)
- Use adequate dosages
- Decrease provocative factors
- Get adequate sleep
- Avoid skipping meals
- Decrease Caffeine intake (very important)
- Decrease Migraine Headache Triggers
- Decrease Tyramine-Vasoactive Amines
III. Management: First-Line Medications (only FDA approved medications for Headache under age 12 years)
IV. Management: Second-Line Medications
- Appear to be safe and effective for age 6 and over
- However onset of Migraine Headaches at age 6 years old is unusual
- Consult pediatric neurology for suspected Migraine Headaches in younger children (age 6-12 years)
- Consider combining Triptan with Acetaminophen or NSAID (see first-line medications as above)
-
Triptans (Adjust dose for weight)
- Sumatriptan (Imitrex, FDA approved for age 12 years and older, intranasal costs $50/dose in 2019)
- Almotriptan (Axert, FDA approved for age 12 years and older)
- Dose: 6.25 to 12.5 mg orally and may repeat in 2 hours (max total 25 mg/day)
- Rizatriptan (Maxalt, FDA approved for age 6 years and older, least expensive: $2/pill in 2019)
- Weight <40 kg: 5 mg orally (do not use if on Propranolol)
- Weight >40 kg: 10 mg orally (5 mg if on Propranolol)
- Zolmitriptan (Zomig, FDA approved for age 12 years and older, costs $80/dose in 2019)
- Intranasal: 2.5 mg (1 spray) in one nostril (maximum dose: 5 mg, may repeat in 2 hours)
V. Management: Anti-emetics
- Precautions: Dystonic Reaction
- Prepare patients and parents for the risk of Dystonic Reactions (rare, but may occur esp. in teens)
- Treat with Diphenhydramine 0.1 mg/kg up to 25 to 50 mg
- Agents
- Prochlorperazine (Compazine) 0.5 mg/kg/dose
- Promethazine (Phenergan) 0.25 to 0.5 mg/kg/dose q8 hours
- Metoclopramide (Reglan) 1-2 mg/kg up to 10 mg q4 hours
VI. Management: Prophylaxis (for frequent or disabling Headache)
- See Migraine Prophylaxis
- Background
- Migraine Prophylaxis appears to be less effective in children than in adults
- Guidelines recommend lifestyle and Behavior Modification
- May still trial a 2-3 month prophylactic medication if other measures are failing
- Oskoui (2019) Neurology 93(11):500-9 +PMID:31413170 [PubMed]
- Migraine Prophylaxis appears to be less effective in children than in adults
- Indications
- Migraine Headaches 4 or more per month or
- Migraine Headaches 1 or more per month that is severe and incapacitating
- Age over 12 years old
- Age under 10 to 12 years old
- First Line
- Propranolol (Inderal)
- Only agent proven effective in children
- Wasiewski (2001) J Child Neurol 16:71-8 [PubMed]
- Propranolol (Inderal)
- Second Line
- Topamax (Topiramate)
- FDA approved in 2014 for age over 12 years old
- Topamax (Topiramate)
- Third Line
- Amitriptyline (Elavil) up to 1 mg/kg/day
- Carbamazepine (Tegretol)
- Valproic Acid (Depakene)
- Keppra (Levetiracetam)
- Other options that may have benefit
- Cyproheptadine (Periactin) 2 to 8 mg orally at bedtime
- Less tolerated in adolescents due to stimulated appetite and weight gain
- Riboflavin (Vitamin B2) 100 to 400 mg/day
- Magnesium
- Melatonin
- Cyproheptadine (Periactin) 2 to 8 mg orally at bedtime
- First Line