US Pharm. 2014;39(3):56-60.
ABSTRACT: Migraines are common in the pediatric population, but they
are often overlooked or misdiagnosed. Children can exhibit a variable
array of symptoms that are atypical of the symptoms that occur with
adult migraines. Nonpharmacologic strategies, such as rest and sleep,
are the preferred therapies for mild-to-moderate migraines in children.
Numerous classes of drugs are available to treat acute migraine attacks.
Prophylactic therapy is recommended for children whose migraines are
frequent and severe. Pharmacists can provide guidance on product
selection and counsel parents and adolescents on the proper use, dosing,
and side effects of medications in order to maximize the effectiveness
of these treatments.
Migraines are chronic headaches that occur in individuals of all
ages. Symptoms associated with migraine can vary in severity and
duration, making it difficult for the patient to identify the
appropriate treatment. In children, the identification of migraines can
be particularly problematic, since symptoms can present in a variety of
ways that differ considerably from those occurring in adults with
migraines. Children may have difficulty expressing the location and
extent of the pain caused by the migraine. Over time, a clearer
understanding of migraine etiology has developed, and parents are now
better equipped to care for their child’s chronic disorder. It is common
for parents whose child is in pain to try nonprescription treatments
before seeking professional support. Pharmacists, as the most accessible
health specialists, have a unique opportunity to assist parents by
identifying possible migraine indicators and assisting in the
formulation of a suitable treatment plan for the child.
Migraine occurs frequently in the pediatric population. Prevalence
differs among age groups, but increases with age. The prevalence of
migraines in children aged 2 to 7 years is 3%; prevalence in those aged 7
to 11 years is 4% to 11%; and that in individuals aged 11 to 21 years
is 8% to 23%. Migraine onset typically occurs at an earlier age in boys
than in girls, at 7.2 years and 10.9 years, respectively. At the onset
of puberty, girls are three times more likely than boys to have
migraines. It is estimated that about one-fourth of children suffering
from migraines will no longer have symptoms at age 25 years.1
Headaches, one of the top five health problems in children, rank third in emergency room visits.1 The prevalence of migraine has been increasing recently, owing in part to improved diagnostic procedures.2,3
With the rising prevalence in the pediatric population comes a growing
concern about the physical pain and psychological effects experienced by
children, especially when the migraines go untreated.
The basic mechanism behind migraine involves profound sympathetic
nervous system activation and subsequent overcompensation, with dilation
of extracranial and intracranial arteries.4 The pain
associated with migraine can be attributed to the magnitude of arterial
dilation. Migraines can be triggered by a variety of environmental,
psychological, and physiological factors (TABLE 1). Environmental
triggers, examples of which include lighting, strong odors, high
altitude, and quick changes in ambient temperature, may be the most
easily addressed and modified. Psychological triggers, while important
catalysts, may be more difficult to avoid. Depression, stress, and
anxiety are all factors that can incur headaches. Lastly, physiological
triggers also can contribute to migraines, but are often overlooked.
These include fatigue, travel, illness, lack of sleep, and skipping a
CLINICAL PRESENTATION AND DIAGNOSIS
The diagnosis of migraine in children is difficult because of the
variability of symptoms children may exhibit during an attack. In
general, migraines are characterized by severe, pulsating headaches
located in the temple area. Migraines in younger children manifest in a
bilateral fashion, concentrated in the frontal or temporal regions. In
contrast, older children usually exhibit unilateral headaches located in
the temporal area. Migraines in all pediatric age groups can occur with
or without aura; however, migraine with aura presents in only 20% of
There are several indicators of aura, although children often have
difficulty identifying and expressing the sensations they feel during
these occurrences. The most common type of aura in children is visual aura,
which has been described as the appearance of zigzag lines, size
distortion, blurry vision, black dots, and kaleidoscopic color patterns.
Other types of aura include dizziness, attention deficit, confusion,
one-sided body weakness, loss of coordination, and agitation. The aura
typically appears 30 minutes before the headache begins and lasts up to
Migraine headaches in children typically last less than 4 hours, but can range anywhere from 10 minutes to 72 hours.2,5
Following the throbbing headache, the child may experience either a
boost of energy or a bout of exhaustion that can last up to several
Migraine symptoms in children include nausea, vomiting, abdominal
cramps, sleep disorders, hypersomnia, and sensitivity to light and
sound. Sleep disturbances due to migraine can decrease total sleep time,
delay sleep onset, increase nighttime awakenings, and heighten daytime
sleepiness (P <.0001).6 Frequently, parents do not
realize that a child is experiencing a migraine because the wide variety
of symptoms makes it difficult to recognize that they signal a migraine
attack. Consequently, migraines often go unnoticed and untreated, with a
direct effect on a child’s quality of life.
In studies using the Pediatric Migraine Disability Assessment
questionnaire, quality-of-life scores in children with migraines were
comparable to those in children with cancer or rheumatoid conditions.7
Children with migraines had higher social and physical operational
levels than children with cancer and other conditions, but lower
emotional and school-functioning levels.7 The
unpredictability of migraines, which can interrupt a child’s school
schedule, may contribute to the self-reports of lower school-functioning
The diagnosis of migraine in children is accomplished primarily by
obtaining a patient’s medical history and performing a physical
examination while applying clinical judgment. Clinical judgment also
plays a role in determining the necessity of additional laboratory
evaluations, such as imaging studies. Radiologic tests are not typically
performed unless the patient has head trauma, a history of seizures, or
substantial instability of headaches.5
Migraine classification is contingent upon the frequency of attacks
and the symptoms present. Migraines can be identified as either acute or
chronic. Migraines occurring up to 14 times a month are categorized as acute episodic,
whereas those occurring 15 or more times a month are considered
chronic. Chronic migraines generally persist for three consecutive
months and account for approximately 60% of migraine cases.5
Some types of migraine present differently from typical migraines. Migraine-associated cyclic vomiting syndrome includes abdominal pain, nausea, retching, photophobia, phonophobia, and headache.5
Cyclic vomiting, which may resolve by adulthood, can cause severe fluid
and electrolyte imbalances and warrants vigorous treatment.
There are also several less common categories of migraine. Acute confusional migraine
occurs after head trauma and includes periods of amnesia, confusion,
and dysphagia. This type of migraine usually lasts only a few hours, but
children may experience persistent episodes.5 Acephalgic migraine
is classified as aura without the headache. These visual disturbances
occur more frequently in girls and commonly include a family history of
Certain types of migraine do not present with a headache. Abdominal migraine occurs in 1% to 4% of children, with onset at approximately age 7 to 12 years.8
This type of migraine, which is more common in girls, consists of acute
episodes of abdominal pain followed by severe periumbilical pain that
lasts for an hour or more. Abdominal migraines are often overlooked or
misdiagnosed by parents, since the child does not usually experience
headache as part of the migraine.
For children with occasional mild migraines, nonpharmacologic
treatment strategies are preferred and offer the advantage of avoiding
side effects. These methods include sleep, biofeedback, relaxation
techniques, and avoidance of all types of triggers (TABLE 1).
Sleep and rest are simple, effective ways to alleviate the pain of acute
migraine headaches. The child should have a quiet, dark, and cool
environment in which to lie down and sleep.9
Relaxation techniques such as self-hypnosis and abdominal breathing
exercises are helpful for aborting headaches. Thermal biofeedback,
another alternative to medication therapy, involves raising the
temperature of a body part, such as a finger, with confirmation from a
thermometer.9 These methods are believed to impede the preliminary sympathetic activation that begins the migraine process.4 Additionally, the autonomic system is “trained” to be less reactive.4
Research has suggested that nonpharmacologic treatment can be
effective in children, although results vary from person to person.4,9 These strategies can be implemented before or in combination with medication therapy.
Although nonpharmacologic methods can help reduce migraine frequency,
medication still may be necessary to alleviate discomfort. The two main
treatment approaches are symptomatic (abortive) therapy (TABLE 2)
and prophylactic therapy. Because a number of drugs are off-label for
use in treating migraines in children and adolescents and their safety
and efficacy have not been established, most dosages listed in TABLE 2
are based on recommendations found in the literature. There is not
clear agreement on which drugs and dosages should be used in this
Symptomatic treatment centers on providing rapid relief. The mainstay
of treatment for acute migraine involves the use of analgesics,
anti-inflammatories, and antiemetics.
Nonprescription Treatment: Nonprescription medications
such as ibuprofen and acetaminophen are commonly used as first-line
treatment since they are proven safe and generally effective in the
treatment of headache. Ibuprofen, the analgesic of choice, is effective
in many children, including those with episodic or chronic tension-type
headaches, and it has been found to be more effective than acetaminophen
for treating migraine. Acetaminophen is usually recommended for
children with episodic or chronic tension-type headaches. Naproxen
sodium is another nonprescription anti-inflammatory medication that has
been shown to be effective for acute treatment of migraine, although
safety and efficacy in children and adolescents have not been
established. Safety is always a concern, especially with medication use
in young children.2 Aspirin is not commonly used to treat
migraines in children because it has been associated with Reye syndrome
when given to those with viral infections.3
The pharmacist should counsel the parent or patient that excessive
use of prescription and nonprescription analgesics can cause rebound
headaches. To prevent rebound headaches, treatment should be limited to
the lowest dosage and the minimum frequency that will provide effective
relief.10 Parents should also be advised that if the headache does not subside or is unbearable, medical attention should be sought.
Prescription Treatment: If insufficient relief
is obtained from nonprescription therapies, prescription medication may
be required. Several classes of prescription drugs are used for children
with migraines: 5-hydroxytryptamine 1 (5-HT1) agonists (triptans),
dopamine antagonists, and dihydroergotamine.
Triptans are serotonin agonists that specifically target migraines.
They are considered safe and effective, although the FDA has not yet
identified exact safe and effective dosages for children under the age
of 12. Clinical trials indicate that almotriptan 12.5 mg is an optimal
dosage and is more effective than placebo for acute migraine relief.
Rizatriptan may be used for acute treatment of migraines, with evidence
supporting its effectiveness in children aged 6 years and older.
Rizatriptan appears to be well tolerated in children and displays
adverse effects that are similar to those in adults. Currently, however,
almotriptan is the only triptan FDA-approved to treat pediatric
migraine (in patients aged 12 years and older). The main adverse effects
with oral triptan use are nausea, fatigue, drowsiness, and dry mouth.3
Triptans are available in other formulations, such as oral
disintegrating tablets and nasal sprays. These formulations may be
useful if treatment with oral agents is not feasible owing to nausea,
risk of choking, or difficulty swallowing. Sumatriptan nasal spray has
been found effective for treatment of moderate-to-severe migraines and
has the advantage of a quicker onset of action compared with oral
tablets.11 Taste alteration is the most common side effect reported for nasal sumatriptan.3 In one study, sumatriptan nasal spray was effective in children and adolescents who experienced multiple headaches.11 Parents and adolescents should be counseled to avoid using triptans for more than six headaches per month.11
Dihydroergotamine is usually reserved for patients who have already
failed other treatments. Although the FDA-approved dosage is limited to a
second dose in 1 hour, children should experience an improvement in
migraine symptoms after about five doses, and the regimen should be
continued until the headache dissipates, up to a maximum of 20 doses.3
The harsh side-effect profile of dihydroergotamines (i.e., nausea,
vomiting, hypertension, anxiety) can be problematic for many children
and adolescents, however.3
In addition to headache, nausea and vomiting are often associated
with migraines. Dopamine antagonists have demonstrated efficacy in
treating migraine-associated nausea and vomiting in the pediatric
population. Two of the most common dopamine antagonists used for
migraines are metoclopramide and prochlorperazine. Prochlorperazine is
more effective than metoclopramide in reducing nausea and vomiting in
acute migraine.3 Extrapyramidal side effects, such as
involuntary movements, uncontrollable speech, and severe restlessness,
are the main concerns with dopamine antagonists.
Children who experience frequent migraines (>3 per month) or
severe, persistent migraine attacks (especially >2 hours in duration)
and have failed to respond to abortive therapy are candidates for
prophylactic therapy, the goal of which is to lessen the frequency and
severity of the headaches.5 This is accomplished by having
the child take a prophylactic medication daily without regard to
migraine manifestations. Although several classes of medications are
used for prophylactic treatment, there are currently no first-line
agents preferred. Therapy is selected after the comorbidities and
adverse-effect profiles of potential treatments have been considered.
The only three medications found to be more effective than placebo in
reducing episodic migraines are propranolol, trazodone, and topiramate.12,13
Other medications used for prophylactic treatment include clonidine,
amitriptyline (especially for migraine associated with anxiety,
depression, and sleep disorders), cyproheptadine, divalproex sodium
(although weight gain in adolescents can affect adherence), metoprolol,
and magnesium oxide.13 Cyproheptadine is a safe first-line agent for children younger than 10 years.
Since nonprescription drugs may be the starting point for
pharmacologic treatment, pharmacists must be knowledgeable about the
causes of and treatments for migraine in children. Pharmacists can
educate parents and caregivers about key migraine triggers and advise
avoidance of patient-specific indicators. This process may help reduce
the frequency of migraine attacks in children. Pharmacists can also
provide guidance on product selection and counsel parents and
adolescents on the proper use, dosing, and side effects of
nonprescription medications in order to maximize treatment
effectiveness. This includes information on rebound headaches. When a
patient receives prescription therapy, the pharmacist should monitor the
patient’s pattern of medication use to ensure adequate symptom control
without overuse of the medication. Lastly, it is important for
pharmacists to counsel parents and patients on possible adverse
reactions and assist in getting the medication changed if the side
effects are unbearable. TABLE 3 lists resources for migraine in children.
Many treatments are available for children who suffer from migraines.
It is common for children to experience the pain of a migraine without
being able to express the symptoms clearly. Parents may have trouble
interpreting their child’s symptoms, since the symptoms can differ from
those for typical adult migraines and may mimic other childhood
disorders. A variety of nonprescription and prescription medications are
available for treatment. Pharmacists have the opportunity to ensure
that children receive not only effective treatment, but also safe
treatment that can be adjusted based upon disease progression or
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3. O’Brien HL, Kabbouche MA, Hershey AD. Treatment of acute migraine in the pediatric population. Curr Treat Options Neurol. 2010;12:178-185.
4. Borins M. Biofeedback, relaxation techniques and attitudinal changes in adolescents with migraines: a feasibility study. Can Fam Physician. 1987;33:417-421.
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6. Esposito M, Roccella M, Parisi L, et al. Hypersomnia in children
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10. Cleveland Clinic. Rebound headaches.
Accessed January 17, 2014.
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12. El-Chammas K, Keyes J, Thompson N, et al. Pharmacologic treatment of pediatric headaches: a meta-analysis. JAMA Pediatr. 2013;167:250-258.
13. Agency for Healthcare Research and Quality. Migraine in children: preventive pharmacologic treatments. Executive summary. Comparative Effectiveness Review. June 2013. AHRQ Publication No. 13-EHC065-EF.
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