Pharmacologic Treatment for Pediatric Migraine Prevention: Practice Guideline Update

Individuals with a family history of migraine are at higher risk of developing migraine, and female sex is a risk factor of migraine that persists into adulthood.1 Disease prevention is the cornerstone of medical care. Migraine has multiple behavioral factors that influence headache frequency. Recurrent headache in adolescents is associated with being overweight, caffeine and alcohol use, lack of physical activity, poor sleep habits, and tobacco exposure.2 Depression is associated with higher headache disability in adolescents.

American Academy of Neurology (AAN ) and American Headache Society (AHS) Practice Guideline Update: Pharmacologic Treatment for Pediatric Migraine Prevention in August, 2019 Reaffirmed October 22, 2022. Replaces "Pharmacological Treatment of Migraine Headache in Children and Adolescents" (December 2004). Endorsed by the American Academy of Pediatrics and the Child Neurology Society.

Following are its major recommendations:

Counseling and Education for Children and Adolescents with Migraine and Their Families

1. Clinicians should counsel patients and families that lifestyle and behavioral factors influence headache frequency. (Level B)

2. Clinicians should educate patients and families to identify and modify migraine contributors that are potentially modifiable. (Level B)

3. Clinicians should discuss the potential role of preventive treatments in children and adolescents with frequent headache or migraine-related disability or both. (Level B)

4. Clinicians should discuss the potential role of preventive treatments in children and adolescents with medication overuse. (Level B)

Starting Preventive Treatment

5. Clinicians should inform patients and caregivers that in clinical trials of preventive treatments for pediatric migraine placebo was effective and the majority of preventive medications were not superior to placebo. (Level B)

6. Acknowledging the limitations of currently available evidence, clinicians should engage in shared decision making regarding the use of short-term treatment trials (a minimum of 2 months) for those who could benefit from preventive treatment. (Level B)

7. Clinicians should discuss the evidence for amitriptyline combined with CBT for migraine prevention, inform them of the potential side effects of amitriptyline including risk of suicide, and work with families to identify providers who can offer this type of treatment. (Level B)

8. Clinicians should discuss the evidence for topiramate for migraine prevention in children and adolescents and its side effects in this population. (Level B)

9. Clinicians should discuss the evidence for propranolol for migraine prevention and its side effects in children and adolescents. (Level B)

Counseling for Patients of Child Bearing Potential

10. Clinicians must consider the teratogenic effect of topiramate and valproate in their choice of migraine prevention therapy recommendations to patients of childbearing potential. (Level A)

11. Clinicians who offer topiramate or valproate for migraine prevention to patients of childbearing potential must counsel these patients about potential effects on fetal-childhood development. (Level A)

12. Clinicians who prescribe topiramate for migraine prevention to patients of childbearing potential must counsel these patients about the potential of this medication to decrease the efficacy of oral combined hormonal contraceptives, particularly at doses over 200 mg daily. (Level A)

13. Clinicians who prescribe topiramate or valproate for migraine prevention to patients of childbearing potential should counsel patients to discuss optimal contraception methods with their health care provider during treatment. (Level B)

14. Clinicians must recommend daily folic acid supplementation to patients of childbearing potential who take topiramate or valproate. (Level A)

Monitoring and Stopping Medication

15. Clinicians must periodically monitor medication effectiveness and adverse events when prescribing migraine preventive treatments. (Level A)

16. Clinicians should counsel patient and families about risks and benefits of stopping preventive medication once good migraine control is established. (Level B)

Mental Illness in Children and Adolescents with Migraine

17. Children and adolescents with migraine should be screened for mood and anxiety disorders because of the increased risk of headache persistence. (Level B)

18. In children and adolescents with migraine who have comorbid mood and anxiety disorders, clinicians should discuss management options for these disorders. (Level B)

Reference:

Maryam Oskoui, Tamara Pringsheim, Lori Billinghurst, Sonja Potrebic, Elaine M. Gersz, David Gloss, Yolanda Holler-Managan, Emily Leininger, Nicole Licking, Kenneth Mack, Scott W. Powers, Michael Sowell, M. Cristina Victorio, Marcy Yonker, Heather Zanitsch, Andrew D. Hershey Neurology Sep 2019, 93 (11) 500-509; DOI: 10.1212/WNL.0000000000008105