Migraine practice guidelines

Practice guideline update summary: Pharmacologic treatment for pediatric migraine prevention

Maryam Oskoui, Tamara Pringsheim, Lori Billinghurst, Sonja Potrebic, Elaine M. Gersz, David Gloss, Yolanda Holler-Managan, Emily Leininger, Nicole Licking, Kenneth Mack, Scott W. Powers, Michael Sowell, M. Cristina Victorio, Marcy Yonker, Heather Zanitsch, Andrew D. Hershey. Practice guideline update summary: Pharmacologic treatment for pediatric migraine prevention.  Neurology Aug 2019,

Abstract

Objective To provide updated evidence-based recommendations for migraine prevention using pharmacologic treatment with or without cognitive behavioral therapy in the pediatric population.

Methods The authors systematically reviewed literature from January 2003 to August 2017 and developed practice recommendations using the American Academy of Neurology 2011 process, as amended.

Results Fifteen Class I–III studies on migraine prevention in children and adolescents met inclusion criteria. There is insufficient evidence to determine if children and adolescents receiving divalproex, onabotulinumtoxinA, amitriptyline, nimodipine, or flunarizine are more or less likely than those receiving placebo to have a reduction in headache frequency. Children with migraine receiving propranolol are possibly more likely than those receiving placebo to have an at least 50% reduction in headache frequency. Children and adolescents receiving topiramate and cinnarizine are probably more likely than those receiving placebo to have a decrease in headache frequency. Children with migraine receiving amitriptyline plus cognitive behavioral therapy are more likely than those receiving amitriptyline plus headache education to have a reduction in headache frequency.

Recommendations The majority of randomized controlled trials studying the efficacy of preventive medications for pediatric migraine fail to demonstrate superiority to placebo. Recommendations for the prevention of migraine in children include counseling on lifestyle and behavioral factors that influence headache frequency and assessment and management of comorbid disorders associated with headache persistence. Clinicians should engage in shared decision-making with patients and caregivers regarding the use of preventive treatments for migraine, including discussion of the limitations in the evidence to support pharmacologic treatments.

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Maryam Oskoui, Tamara Pringsheim, Yolanda Holler-Managan, Sonja Potrebic, Lori Billinghurst, David Gloss, Andrew D. Hershey, Nicole Licking, Michael Sowell, M. Cristina Victorio, Elaine M. Gersz, Emily Leininger, Heather Zanitsch, Marcy Yonker, Kenneth Mack.  Practice guideline update summary: Acute treatment of migraine in children and adolescents. Neurology Aug 2019,

Abstract

Objective To provide evidence-based recommendations for the acute symptomatic treatment of children and adolescents with migraine.

Methods We performed a systematic review of the literature and rated risk of bias of included studies according to the American Academy of Neurology classification of evidence criteria. A multidisciplinary panel developed practice recommendations, integrating findings from the systematic review and following an Institute of Medicine–compliant process to ensure transparency and patient engagement. Recommendations were supported by structured rationales, integrating evidence from the systematic review, related evidence, principles of care, and inferences from evidence.

Results There is evidence to support the efficacy of the use of ibuprofen, acetaminophen (in children and adolescents), and triptans (mainly in adolescents) for the relief of migraine pain, although confidence in the evidence varies between agents. There is high confidence that adolescents receiving oral sumatriptan/naproxen and zolmitriptan nasal spray are more likely to be headache-free at 2 hours than those receiving placebo. No acute treatments were effective for migraine-related nausea or vomiting; some triptans were effective for migraine-related phonophobia and photophobia.

Recommendations Recommendations for the treatment of acute migraine in children and adolescents focus on the importance of early treatment, choosing the route of administration best suited to the characteristics of the individual migraine attack, and providing counseling on lifestyle factors that can exacerbate migraine, including trigger avoidance and medication overuse.