 If
migraine patients have sometimes felt neglected by modern
medicine, children and teenagers who suffer from the condition
have often seemed completely abandoned. Now that new treatments
are available which actually work on most migraine headaches,
it's understandable that kids who suffer should get access
too. But lack of knowledge of the effects of these drugs
in children may be holding some physicians back.
Considering that a seemingly innocuous
drug like aspirin can produce a reaction as dangerous
as Reye's syndrome in kids, such caution seems justified.
The little existing evidence on the treatment of migraine
in children has recently been reviewed by a panel of
neurologists and pediatricians, who have compiled, in
the December 28 issue of Neurology, new guidelines
on the treatment of pediatric migraine.
GUIDELINES
OVERDUE
The guidelines, endorsed by the American Academy of
Pediatrics and the American Headache Society, are long
overdue. Canadian doctors will surely be pleased to
see them, since we currently have no guidelines for
pediatric migraines, and the most recent adult migraine
guidelines, issued by the Canadian Headache Society,
date from 1997.
The review estimated migraine prevalence
among kids aged 11 to 15 to be 8-23%, with rates increasing
through adolescence. Lead author Dr Donald Lewis, of
the Children's Hospital of the King's Daughters in Norfolk,
VA, said the most commonly prescribed migraine treatments
should pose no added risk in children. "We're confident
that the most common pharmacological headache treatments
given to adults are also safe and effective for children,"
he said.
Having evaluated 66 articles and
abstracts that addressed children as young as age three
and up to age 18, Dr Lewis' team concluded that s "both
ibuprofen and acetaminophen are safe and effective for
treating migraine headaches in children and adolescents,"
and sumatriptan nasal spray is also effective in adolescents.
The two most rigorous pediatric
studies of ibuprofen and acetaminophen found that both
clearly outperformed placebo within two hours. One study,
which compared both drugs to placebo, suggested that
acetaminophen has the faster onset of action, but ibuprofen
ultimately brings a greater reduction in pain.
A second study of ibuprofen, however,
found that though it clearly outperformed placebo in
a group of six to 12 year olds, all of the benefit was
concentrated in the boys — girls saw no improvement
over placebo.
TRIPTAN
GREEN LIGHT
Better results have been achieved with intranasal sumatriptan,
at least in older children. This drug has become the
mainstay of adult migraine treatment since its introduction
in 1993. "Triptans are wonderful drugs," said Dr Lewis.
"None have ever been approved for children by the FDA,
but they're widely used in an off-label context."
Anyone reading intranasal sumatriptan's
label might be forgiven for thinking the drug is lethal
to children. Not only does it say that pediatric use
isn't recommended, it goes on to relate the case of
a 14-year-old boy who suffered a heart attack shortly
after taking oral sumatriptan.
"We're happy to set people's minds
at ease about nasal sumatriptan," said Dr Lewis. The
only common adverse effect the panel found in the research
literature was an unpleasant taste. Oral sumatriptan
and the other triptans, while mostly safe, appear to
be less effective in under-18s than in adults, and aren't
recommended.
PREVENTATIVE
LUCK
Finally, the group studied a host of medicines that
have been floated as possible preventive migraine therapy.
The anticonvulsant levetiracetam did well in one trial,
said Dr Lewis, but the study was open-label so the panel
felt unable to formally recommend it. Propranolol, amitriptyline,
trazodone, the antihistamine cyproheptadine, and the
anticonvulsants valproic acid and topiramate lack data
to back up their pediatric use. Clonidine, pizotifen
and nimodipine don't work.
One preventive drug stood out from
the pack. "The calcium channel blocker flunarizine is
a very good drug", said Dr Lewis. "Sadly, it's unavailable
here in the States, but not in Canada. I guess you guys
are just lucky."
Neurology Dec 2004;63:2215-24
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