II. General

  1. See Headache General Measures
  2. Keep medication available at all times (school)
  3. Use adequate dosages
  4. Decrease provocative factors
    1. Decrease Caffeine intake (very important)
    2. Decrease Migraine Headache Triggers
    3. Decrease Tyramine-Vasoactive Amines

III. Management: First-Line Medications (only FDA approved medications for Headache under age 12 years)

  1. Acetaminophen (Tylenol) 15 mg/kg q6 hours
  2. Ibuprofen (Motrin) 10 mg/kg q6 hours
  3. Naproxen Sodium (Anaprox) 5 mg/kg twice daily

IV. Management: Second-Line Medications

  1. Appear to be safe and effective for age 6 and over
    1. However onset of Migraine Headaches at age 6 years old is unusual
    2. Consult pediatric neurology for suspected Migraine Headaches in younger children (age 6-12 years)
    3. Consider combining Triptan with Acetaminophen or NSAID (see first-line medications as above)
  2. Triptans (Adjust dose for weight)
    1. Sumatriptan (Imitrex, FDA approved for age 12 years and older)
      1. Imitrex intranasal is not FDA approved for age 12, but recommended for this age by AAN
      2. Imitrex nasal spray 10 mg (weight 44-85 pounds)
      3. Imitrex nasal spray 20 mg (weight >85 pounds)
    2. Almotriptan (Axert, FDA approved for age 12 years and older)
      1. Dose: 6.25 to 12.5 mg orally and may repeat in 2 hours (max total 25 mg/day)
    3. Rizatriptan (Maxalt, FDA approved for age 6 years and older)
      1. Weight <40 kg: 5 mg orally (do not use if on Propranolol)
      2. Weight >40 kg: 10 mg orally (5 mg if on Propranolol)
    4. Zolmitriptan (Zomig, FDA approved for age 12 years and older)
      1. Intranasal: 2.5 mg (1 spray) in one nostril (maximum dose: 5 mg, may repeat in 2 hours)

V. Management: Anti-emetics

  1. Precautions: Dystonic Reaction
    1. Prepare patients and parents for the risk of Dystonic Reactions (rare, but may occur esp. in teens)
    2. Treat with Diphenhydramine 0.1 mg/kg up to 25 to 50 mg
  2. Agents
    1. Prochlorperazine (Compazine) 0.5 mg/kg/dose
    2. Promethazine (Phenergan) 0.25 to 0.5 mg/kg/dose q8 hours
    3. Metoclopramide (Reglan) 1-2 mg/kg up to 10 mg q4 hours

VI. Management: Prophylaxis (for frequent or disabling Headache)

  1. See Migraine Prophylaxis
  2. Indications
    1. Migraine Headaches 4 or more per month or
    2. Migraine Headaches 1 or more per month that is severe and incapacitating
  3. Age over 12 years old
    1. See Migraine Prophylaxis
  4. Age under 10 to 12 years old
    1. First Line
      1. Propranolol (Inderal)
        1. Only agent proven effective in children
        2. Wasiewski (2001) J Child Neurol 16:71-8 [PubMed]
    2. Second Line
      1. Amitriptyline (Elavil) up to 1 mg/kg/day
      2. Cyproheptadine (Periactin) 2 to 8 mg PO qhs
      3. Propranolol (Inderal)
      4. Carbamazepine (Tegretol)
      5. Valproic Acid (Depakene)
      6. Topamax (Topiramate)
        1. FDA approved in 2014 for age over 12 years old
      7. Keppra (Levetiracetam)

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