Guidelines raise awareness of childhood migraine

Migraine headaches are common in children and occur with increasing frequency through adolescence. The reported prevalence increases from 3% (age three to seven years) to 4%-11% (age seven to 11 years) to 8%-23% (age 11 to 15 and up). The mean age at onset is 7.2 years for boys and 10.9 years for girls.

The American Academy of Neurology recently developed a Practice Parameter on the pharmacologic treatment of migraine headache in children and adolescents. The new guidelines have been endorsed by the American Academy of Pediatrics and the American Headache Society. The document was published in the Dec. 28, 2004, issue of the journal Neurology.

"Migraine headaches are very common in children," said Donald Lewis, M.D., lead author of the guidelines and a professor of Pediatrics and Neurology at Children's Hospital of the King's Daughters-Eastern Virginia Medical School in Norfolk. "Unfortunately, they are often misdiagnosed as sinus headaches, stress, or the need for glasses."

The primary goal of publishing the Practice Parameter was to raise awareness of the prevalence of migraines in children among healthcare professionals, Wenzel said. Lewis concurred. "It would be great if we could get the word out to pharmacists that migraines are so common in kids," he said.

Lewis suggested that if pharmacists are approached by a parent and child for a consultation about the youngster's headache, they should ask the child questions such as, "Where does it hurt?" and "Do you feel sick to your stomach?" If the answers are "In the front or to one side of my head" and "Yes, I feel really nauseous," then pharmacists should suggest the possibility of a migraine, he said. Wenzel added that pharmacists should spend a good deal of their time educating parents and school nurses about the prevalence and management of migraines in children.

The authors of the guidelines concluded that ibuprofen at a dose of 7.5 to 10 mg per kg of body weight is safe and effective for the acute treatment of migraine in children greater than six years of age. The authors also advised that acetaminophen at a dose of 15 mg per kg of body weight is probably a safe and effective acute therapy in kids and that sumatriptan (Imitrex, GlaxoSmithKline) nasal spray, 5 mg and 20 mg, should be considered for the treatment of migraine in adolescents (greater than 12 years of age).

The calcium-channel blocker flunarizine is probably effective for preventive therapy and could be considered for this purpose, the authors noted, but it is not available in the United States. They further determined that insufficient evidence exists to make any recommendations concerning the use of cyproheptadine, amitriptyline, divalproex sodium (Depakote, Abbott Laboratories), topiramate, or levetiracetam (Keppra, UCB Pharma).

In terms of nondrug therapies, Wenzel recommended reducing intake of caffeine and foods high in nitrates. He said that regular sleep patterns are important, as well. In addition, the findings of several well-designed studies suggest that biofeedback can be of help.