The treatment of migraine headaches in children and adolescents

Effective management of migraine headache in children and adolescents requires a balanced approach with an individually tailored regimen targeted to treat an acute attack at its onset, blended with bio-behavioral measures, and, in about 1/3 of patients, daily preventive medicines. The key first step is to assess the disability imposed by the recurrent headache pattern, the headache "burden." Once the burden is established decisions can be made toward selecting the most appropriate course of action. All patients will benefit from some basic bio-behavioral suggestions such as regular sleep, exercise, and eating schedule, moderation of caffeine, and identification of triggers. In addition, all patients should have a readily available analgesic to be used at the onset of a migraine attack. A subset of migraineurs will have sufficient headache burden to necessitate use of daily preventative medications. Unfortunately, there is limited controlled data to provide a comprehensive, evidence-based guideline, however, the most rigorously studied agents for acute treatment are ibuprofen, acetaminophen, and "triptan" nasal spray forms of sumatriptan and zolmitriptan; all of these have shown safety and efficacy in controlled trials. For preventive treatment, flunarizine, not available in the U.S., is the only agent that has demonstrated efficacy in placebo controlled trials, but encouraging data is emerging regarding the use of several antiepileptic agents such as topiramate, disodium valproate, and levetiracetam, as well as the antihistamine cyproheptadine and the antidepressant amitriptyline.