Dr Maryam OskouiMaryam Oskoui, MD, MSc
In a joint effort, the American Academy of Neurology (AAN) and American Headache Society (AHS) have released 2 new guidelines for the prevention and treatment of migraine in pediatric patients. The guidelines are endorsed by the American Academy of Pediatrics and the Child Neurology Society.1

Notably, the guidelines refrain from addressing the newest migraine therapies, including the recently-approved calcitonin gene-related peptide (CGRP) antibodies, and devices for migraine in children and teens despite their success in adult patients, as there is little data on their efficacy in that patient population.

One set of guidelines covers the acute treatment, with a focus on the importance of early intervention, suggestions for the best routes of administration for individual migraine attacks, and how to offer counseling related to lifestyle factors, such as avoiding triggers and medication overuse.2 The other set, which focus on migraine prevention in the pediatric population, recommend education on modifiable risk factors that can sway migraine frequency, as well as the management of comorbid disorders associated with ongoing migraine and the use of shared decision-making in the treatment process.3

“The current guidelines are a further step in this goal and provide a framework for the clinical community to apply an evidence basis to the management of migraine in children and adolescents,” guideline author Andrew Hershey, MD, PhD, director of the division of neurology and a headache medicine specialist at Cincinnati Children’s Hospital, told NeurologyLive. “It additionally reveals significant gaps that remain to be filled.”

Hershey, who is also a professor of pediatrics at the University of Cincinnati College of Medicine, and colleagues included a number of suggestions for further research, with specific interest in working to overcome difficulties in clinical trial design born from the elevated placebo response rates among children with migraine, as well as the need to further study novel therapeutics as well as evidence regarding behavioral changes on reducing the burden of migraine, among others.

“We reviewed all of the available evidence, and the good news is that there are evidence-based treatments for children and teens that are effective for treating migraine attacks when they occur,” said guideline lead author Maryam Oskoui, MD, MSc, pediatric neurologist, McGill University, in a statement. “However, most medications that are designed to prevent recurrent migraine attacks are only as good as placebo when used in children and there is little evidence to guide treatment of related symptoms such as nausea and sensitivity to light. It should be noted that these medications, as well as placebo, were effective in more than 50% of the patients.”

READ MORE: Guidelines co-author Andrew Hershey, MD, PhD discusses how the guidelines will influence clinical practice.

The recommendations suggest that children and teenage patients with migraine should have detailed histories and physical examinations, including neurological exams, conducted by a neurologist or headache specialist. The guidelines are in favor of intervention at the soonest possible point in acute management, recommending the use of ibuprofen, triptans, and combination sumatriptan/naproxen to relieve pain during attacks. The group acknowledged that there is a high level of confidence that those who are administered oral sumatriptan/naproxen and zolmitriptan nasal spray are more likely to be headache-free at 2 hours compared to placebo.

With regard to migraine prevention in pediatric patients, the authors note that patients and caregivers should be made aware of the limitations of the available evidence. They suggest that shared-decision making should be conducted to assess the possible use of 2-month treatment trials in addition to a discussion regarding the use of cognitive behavioral therapy (CBT) in combination with amitriptyline, followed by topiramate and propranolol.

It is important to note the potential adverse effects of these therapies, specifically the risk of suicidal ideation associated with amitriptyline, the guidelines state, though Oskoui said in a statement that “the benefit of CBT alone or in combination with other treatments in migraine prevention warrants further study.”

Botulinum toxin was also outlined in the guidelines for the prevention of migraine, though its lack of effectiveness in children compared to its success in adults in troublesome. As well, the education of patients and their caregivers about migraine and identifying its associated aspects, such as negative impacts on physical activity, weight, caffeine intake, sleep, and hydration, is an integral part of the guideline. 

Oskoui, Hershey, and colleagues indicated that the development of healthy lifestyle habits related to diet, exercise, and sleep are vital to help address the comorbid mood disorders which can worsen migraine and delay recovery from attacks.

“Since 2004, there have been additional studies of the efficacy of acute and preventive treatments for migraine in children and adolescent that has included approval for these treatments by the US FDA and the EMA,” Hershey said. “The use of a multidisciplinary approach is becoming clearer with a combination of acute, preventive, and biobehavioral therapy.”
REFERENCES
1. AAN Issues Guidelines for Treatment of Migraine in Children and Teens [press release]. Minneapolis, MN: American Academy of Neurology; Published August 14, 2019. Accessed August 14, 2019.
2. Oskoui M, Pringsheim T, Holler-Managan Y, et al. Practice guideline update summary: Acute treatment of migraine in children and adolescents. Neurology. 2019;93:1-13. doi: 10.1212/WNL.0000000000008095.
3. Oskoui M, Pringsheim T, Billinghurst L, et al. Practice guideline update summary: Pharmacologic treatment for pediatric migraine prevention. Neurology. 2019;93:1-10. doi: 10.1212/WNL.0000000000008105.