Migraine Management

Introduction to Migraine

• Migraine presentation in children differs from adults, with attacks often being shorter (2-72 hours), headache being more frequently bilateral, and gastrointestinal symptoms being commonly prominent, requiring active involvement from family members, teachers, and healthcare providers 1
• Chronic migraine is defined as headaches occurring on ≥15 days per month for at least 3 months, with migraine features on ≥8 days per month 1

Medication Efficacy for Prevention

• Propranolol is more effective than metoprolol for headache prevention, with consistent evidence supporting its efficacy in preventing migraine attacks, according to the American Academy of Family Physicians 2
• The US Headache Consortium found consistent evidence for the efficacy of propranolol at doses of 120-240mg daily in preventing migraine attacks 2
• Beta-blockers with intrinsic sympathomimetic activity are ineffective for preventing migraine 2
• The following medications are recommended for migraine prevention:

Acute Migraine Treatment

• The American Academy of Family Physicians recommends NSAIDs, such as aspirin 650-1000 mg, ibuprofen 400-800 mg, or naproxen sodium 275-550 mg, as first-line options for acute migraine treatment 8
• Combination analgesics, including acetaminophen, aspirin, and caffeine, are also recommended as first-line options by the American Academy of Family Physicians for acute migraine treatment 8
• Triptans (e.g., sumatriptan, rizatriptan, zolmitriptan, naratriptan) are recommended for acute headache treatment with strong evidence 6
• Antiemetics (e.g., metoclopramide IV) are useful for acute headache treatment, particularly when nausea and vomiting are present 6
• Paracetamol (acetaminophen) is recommended as the first-line treatment for acute migraine attacks, with a dosage of 650-1000 mg every 4-6 hours (maximum 4g/day) 9
• Triptan + NSAID combination is the most effective approach for moderate to severe attacks and should be started as soon as possible after migraine onset 10, 8

Lifestyle Modifications

• Regular sleep schedule, consistent meal times, adequate hydration, and regular exercise program are recommended for headache management 11
• Stress management techniques such as yoga, cognitive-behavioral therapy, and mindfulness are recommended for headache management 11
• Limit caffeine intake to prevent headache exacerbation 11
• Aerobic exercise, such as 40 minutes of activity, three times weekly, is recommended for patients 3
• Progressive strength training, 2-3 times weekly for 30-60 minutes, is also recommended for patients 3
• Cognitive-behavioral therapy (CBT) is a recommended behavioral intervention 3
• Physical therapy is strongly recommended for tension-type headache management, including techniques such as thermal methods, trigger point massage, and mobilization/manipulation 7

Comorbid Conditions and Special Considerations

• Addressing comorbid conditions, such as depression, anxiety, sleep disorders, obesity, and chronic pain conditions, improves treatment outcomes, and consideration of amitriptyline, sleep hygiene improvement, weight loss encouragement, and appropriate therapies for chronic pain conditions is recommended 1
• Bed rest alone might suffice for children with short-duration attacks, and regular assessment for signs of intracranial hypertension is recommended 1, 12
• Monitor for neurological symptoms related to Chiari malformation progression, and be alert for development or worsening of syringomyelia 12

Treatment Evaluation and Referral

• Evaluate the effectiveness of treatment after 2-3 months and consider changing medication if there is no adequate response 9
• Consider preventive treatment if migraines occur ≥2 days per month with significant impact despite optimized acute treatment, with a treatment duration of 3-4 months to reach maximal efficacy 1, 3, 4, 5, 6, 7
• Using a headache diary helps determine the effectiveness of treatment, identify excessive use of analgesics, and follow the progression of migraine 9
• Identify and address medication overuse, defined as the use of simple analgesics >15 days/month or triptans/combination analgesics >10 days/month 1
• Referral to a neurology/headache specialist is indicated when diagnosis is uncertain, treatment is ineffective despite appropriate interventions, significant comorbidities complicate management, or medication overuse cannot be managed in primary care 1