Limited clinical trials and limited options present challenges in the treatment of pediatric migraine.
It is reported that up to 5% of children under 12 years of age may experience migraine. Among these patients the average age at first migraine attack is six.
The prevalence of migraine increases dramatically at adolescence, with some studies reporting migraine incidence in nearly 20% of girls and over 10% of boys.
Migraine in children and adolescents is associated with diminished quality of life and significantly impaired functioning, including poor school performance and poor social adaptation. While individual migraine events tend to be of shorter duration among pediatric patients, there is no reason to believe that they are any less painful, or any less deserving of effective treatment. In fact the treatment of pediatric migraine should, if anything, be more highly prioritized, as poor treatment in the early years of migraine disease may be associated with disease progression in terms of both the frequency of attacks and their severity.
Yet there are relatively few clinical trials investigating the use of acute agents in the treatment of pediatric migraine. One impediment to conducting such trials may be the relatively short duration of many pediatric migraine events and the relatively high placebo effect among children.
The study summarized below reviewed clinical trials published on the acute treatment of pediatric migraine through 2004.
Summary of the findings.
- Acetaminophen and ibuprofen were both found to be more effective than placebo.
- Neither acetaminophen nor ibuprofen were better, and each was associated with only minor adverse events.
- Nasal spray sumatriptan was more effective than placebo, but was associated with significantly more adverse effects than acetaminophen or ibuprofen.
- No differences were found between oral triptans and placebo.
The publication:
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Pediatrics. 2005 Aug;116(2):e295-302.
Symptomatic treatment of migraine in children: a systematic review of medication trials.
Damen L, Bruijn JK, Verhagen AP, Berger MY, Passchier J, Koes BW.
Department of General Practice, Erasmus Medical Centre, PO Box 1738, 3000 DR, Rotterdam, The Netherlands.
There is no coherent body of evidence on symptomatic treatment of childhood migraine available.
The objective of this review is to describe and assess the evidence from randomized and clinical controlled trials concerning the efficacy and tolerability of symptomatic treatment of migraine in children.
Databases were searched from inception to June 2004. Randomized and controlled trials evaluating the effects of symptomatic treatment in children (<18 years old) with migraine were selected and headache (HA) clinical improvement was used as the outcome measure.
A total of 10 trials were included in this review with a total of 1575 patients included in this review. Improvement often was regarded as being clinically relevant when the patients’ HA declined by at least 50%.
When compared with placebo, acetaminophen and ibuprofen significantly reduced HAs. We conclude that there is moderate evidence that both acetaminophen and ibuprofen are more effective in reduction of symptoms 1 and 2 hours after intake than placebo and that these medications were associated with minor adverse effects. No clear differences in effect were found between acetaminophen and ibuprofen or nimesulide.
Regarding the nonanalgesic interventions, nasal-spray sumatriptan, oral sumatriptan, oral rizatriptan, oral dihydroergotamine, intravenous prochlorperazine, and ketorolac were evaluated.
When compared with placebo, nasal-spray sumatriptan seemed to significantly reduce HAs. We conclude that there is moderate evidence that nasal-spray sumatriptan is more effective in reduction of symptoms than placebo but with significantly more adverse events.
No differences in effect were found between oral triptans and placebo. All medications were well tolerated, but significantly more adverse events were reported for nasal-spray sumatriptan compared with placebo.
We also conclude that there is moderate evidence that intravenous prochlorperazine is more effective than intravenous ketorolac in the reduction of symptoms 1 hour after intake. No differences in effect were found between oral dihydroergotamine and placebo.
CONCLUSIONS: Acetaminophen, ibuprofen, and nasal-spray sumatriptan are all effective symptomatic pharmacologic treatments for episodes of migraine in children.
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