Migraine Management in Children

Acute Treatment

Administer medication as early as possible during the attack to maximize efficacy, according to the American Academy of Family Physicians 1
Acetaminophen alone is less effective than ibuprofen or combination therapy for mild to moderate migraine in children, as recommended by the American Academy of Family Physicians 2, 3
Triptans should not be used if the child has uncontrolled hypertension, basilar or hemiplegic migraine, or risk factors for heart disease, as advised by the American Academy of Family Physicians 2, 3
If nausea or vomiting is prominent, use a nonoral route of administration and add an antiemetic, according to the American Academy of Family Physicians 2, 3
Metoclopramide is safe and effective for migraine-associated nausea, as stated by the American Academy of Family Physicians, although the recommendation is also found in Praxis Medical Insights 4

Evaluate for preventive treatment if the child has two or more migraine attacks per month causing disability for 3+ days, or rescue medication use more than twice weekly, as recommended by the American Academy of Family Physicians 2, 3, 4
Evidence-based first-line options for preventive therapy include propranolol, which has the best safety data in children, and amitriptyline, if propranolol is contraindicated, as stated by the American Academy of Family Physicians, although the recommendation is also found in Praxis Medical Insights 2, 4
Avoid topiramate, valproate, and candesartan due to potential adverse effects on growth, development, and cognition in children, as advised by Praxis Medical Insights, although other sources may also recommend this 4

Maintain consistent sleep schedule with adequate hours, and ensure proper hydration throughout the day, as recommended by the Annals of Internal Medicine and the American Academy of Family Physicians, although the recommendation is also found in Praxis Medical Insights 4, 5
Encourage regular moderate-to-intense aerobic exercise, as recommended by the Annals of Internal Medicine 5
Use a headache diary to identify specific triggers, such as foods, environmental factors, stress, and weather changes, as advised by the American Academy of Family Physicians 1, 3

Obtain neuroimaging if the child has headache worsened by Valsalva maneuver, headache that awakens from sleep, progressive worsening pattern, or abnormal neurologic examination findings, as recommended by the American Academy of Family Physicians and Praxis Medical Insights 1, 4

Monitor frequency with headache diary for 8-12 weeks, as recommended by the American Academy of Family Physicians 1, 3
If ≥2 attacks/month with significant disability, initiate preventive therapy with propranolol, as advised by the American Academy of Family Physicians 2, 3

Sumatriptan nasal spray (5-20 mg) is effective for adolescents and can be considered for a 12-year-old with moderate to severe attacks when NSAIDs fail after 2-3 episodes, according to the American Academy of Neurology 6
Intranasal formulations are particularly useful when significant nausea or vomiting is present early in the attack, as recommended by the American Headache Society 6

Addressing obesity, if present, is crucial as it is a risk factor for migraine chronification, as noted by the American Academy of Neurology 7

Preventive medications require an adequate trial duration of at least 2-3 months before declaring treatment failure, as suggested by the American Academy of Neurology 7
The American Academy of Neurology recommends that each medication should be tried for 2-3 headache episodes before switching, to ensure adequate assessment of efficacy 6