Preventing and treating migraines in children and adolescents

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The American Academy of Neurology (AAN) and American Headache Society (AHS) released updated guidelines in the September 10, 2019, issue of Neurology on acute management and prevention of headache in children and adolescents. The guidelines cover appropriate OTC and prescription medications, migraine-healthy habits, and patient counseling points. The acute treatment guideline focuses on diagnosis, treatments, management of associated symptoms, and counseling pearls. The prevention guideline focuses on lifestyle and behavioral factors to minimize headaches, medications used to prevent headaches, and counseling recommendations for patients of childbearing age who may be using these medications. Pediatric migraine is diagnosed in those having at least five headaches over the last year that last 2 to 72 hours with accompanying symptoms if left untreated. At least two of four additional features should be present (pulsatile quality, unilateral, worsening with activity or limiting activity, moderate to severe in intensity), along with nausea, vomiting, photophobia, or phonophobia. The treatment goal is to alleviate the pain and address the accompanying symptoms. Treatment should be given early in the migraine attack when the pain is still mild. Acetaminophen oral solution (15 mg/kg) and ibuprofen oral solution (10 mg/kg) are recommended as initial treatment for pain in children and adolescents, and triptans are listed as an option primarily for adolescents. An alternative triptan can be tried if the first one fails, and combination treatment with a triptan and ibuprofen or naproxen can be offered to those who have an incomplete response to triptan therapy. Recommendations for maximum monthly use are also included to ensure patients and caregivers understand that no more than 14 days of ibuprofen or acetaminophen should be used and no more than 9 days of triptans. No more than 3 straight months of combination therapy should be used to avoid overuse headache. Antiemetics should also be offered to help with migraine-associated nausea, and nonoral formulations of triptans may be preferable in these patients. For prevention, the guideline notes that many monotherapy treatments (e.g., amitriptyline, valproate) tested for pediatric migraine have failed to demonstrate superiority over placebo, except amitriptyline with cognitive behavioral therapy, propranolol, and topiramate. The teratogenic effects of topiramate or valproate must be considered, and patients of childbearing age must be educated on these risks. Education on lifestyle and behavioral factors also is important. Factors that may contribute to headaches include being overweight, caffeine and alcohol use, lack of physical activity, poor sleep habits, and tobacco use. Pharmacists are well positioned to address appropriate use of OTC and prescription medications to manage headaches in children, including proper dosing, maximum use criteria, and limitations of preventive therapies. Inform patients and caregivers that updated guidelines have been released on managing headaches in children and adolescents. Educate them about appropriate use of medications and healthy lifestyle practices that can help to prevent headache, such as eating well-balanced meals, establishing a sleep schedule, not smoking, minimizing stress, and exercising.