Kids Korner Archive - #166

By Donald W. Lewis, MD, Pediatric Neurologist, Children’s Hospital of The King’s Daughters, Norfolk, Virginia

Doctor: “Pretend that you are a firefighter.”
Child: “Okay.”
Doctor: “Which is easier for you to put out, a small brush fire or a raging forest fire?”
Child: “The small brush fire!”
Doctor: “Okay, think of your headaches as fires. It is much easier to put out a small headache as it’s beginning, than a big one that has been hurting for hours or days!”

Migraine headaches are very common in kids and teenagers, particularly migraine without aura. The key feature of migraine is episodes of intense, disabling headaches, separated by symptom-free intervals. Characteristic symptoms include unilateral (one-sided) or bilateral (both sides or across the forehead) location and a pulsing or throbbing quality to the pain. The pain is moderate to intense and aggravated by routine physical activity, such as walking or climbing stairs. Accompanying symptoms include nausea and vomiting, and sensitivity to light and sound, which can be as disabling as the pain. The latter two features may have to be inferred by a child’s behavior, for example, if the child withdraws to a quiet, dark place during an attack.

Once the diagnosis of migraine is established, a balanced, flexible and individually tailored treatment plan can be put in place. Comprehensive migraine treatment now embraces an approach that includes both bio-behavioral interventions (sleep, exercise and diet) and pharmacological measures. (For information on behavioral methods, see NHF Head Lines 162). Medications can treat and stop attacks, prevent attacks from starting, and treat any associated nausea or vomiting.

Here, we focus on treating attacks that have already started, i.e., putting out the small brush fires before they get big. These “acute” treatments represent the primary weapon for migraine management. Regardless of the acute treatment selected, there are several general guidelines regarding the use of pain medicines that must be part of the patient’s education process. The primary message is “give enough medication and give it early.”

1. Take the medicine as soon as possible after the headache begins (within 20 minutes).
2. Take the appropriate dose. Don’t “baby” the headache.
3. Have the medicine available at the location where the child usually has his or her headaches. Most migraines begin at school, so the treatment should start there and not wait until the patient gets home! Make sure you’ve filled out the school’s medicine forms so that the school will be able to give the medicine.
4. Avoid too much pain medicine, or “analgesic overuse,” which is defined as more than three doses of a particular analgesic per week.
   There are no drugs approved by the US Food and Drug Administration for the acute treatment of migraine in children. There is, however, a growing body of research on treating migraine in young people.

For children less than 12 years of age, ibuprofen (7.5 to 10 mg/kg) and acetaminophen (15 mg/kg) have demonstrated value for the acute treatment of migraine. Don’t give up on over-the-counter (OTC) medicines until you have used them early and at the right dose!

Sometimes these OTCs don’t work. For adolescents, it is reasonable to consider using one of the triptans. The triptans have revolutionized acute migraine treatment for adults. Unfortunately, none of the triptans has been approved by the FDA for use in children and adolescents, even though multiple studies have demonstrated the safety of their use in this population. So far, sumatriptan (5 and 20 mg) and zolmitriptan (5 mg) in the nasal spray forms, and rizatriptan (5 and 10 mg) and almotriptan (12.5 mg) in the tablet form have demonstrated both safety and effectiveness in carefully conducted research in adolescents 12 to 17 years of age. We may soon have more information about combination medications, such as Treximet®, which is a combination of 85 mg of sumatriptan and 550 mg of naproxen.

Treating children and adolescents for migraine is important as it translates into decreased disability as these patients progress into adulthood, lessening the burden of migraine over the course of their lives. In the future, we anticipate further advances in understanding the molecular genetics of migraine, advances that will translate into improved care of the pediatric patient with migraine headache.