How to treat children with migraine in primary care
There are numerous migraine treatment options available for adults, which include acute and preventive medications, medical devices, supplements, and acupuncture. While some of these treatment options are currently unavailable for children, particularly some of the newer medication that has yet to be trialled on children, there is still a range of ways that you can treat children with migraine.
Here is an overview of how you can treat a child with migraine in primary care.
Understanding and managing their migraine
Self-management is also an important part of living with migraine. We recommend that people with migraine use a migraine diary to help them understand the patterns of their migraine and identify possible migraine attack triggers. This can help them avoid or reduce certain triggers such as dehydration or stress.
Stress is a common migraine trigger in children. Stress-related migraine attacks can be the result of a negative experience in the child’s life or common experiences such as the change of moving to secondary school or the pressures of exams.
However, it can also be the stress of ‘doing too much’ that can trigger migraine attacks in children, even if that involves a lot of activity that they find fun and enjoyable.
It is therefore important to give children, their parents and carers, information on managing stress but also pacing themselves. It is not about telling children that they can’t do certain things, but helping them understand that pacing their activity might help them manage their migraine better.
Acute medication for migraine
Migraine in children can often be treated effectively with moderate management that includes avoiding or reducing their migraine attack triggers and simple analgesia, such as paracetamol or a non-steroidal anti-inflammatory drug (NSAID), usually ibuprofen.
If treatment with a simple analgesic is ineffective, a migraine attack may be treated with a 5HT1-receptor agonist (preferably intranasally), such as sumatriptan or zolmitriptan [unlicensed use]. If a child does not respond to one 5HT1-receptor agonist, an alternative 5HT1-receptor agonist can also be tried.
If a 5HT1-receptor agonist alone is ineffective, consider combination therapy with an NSAID, or paracetamol. In addition to their use as antiemetics, metoclopramide hydrochloride [unlicensed use] or prochlorperazine [unlicensed use], can also be given at the onset of migraine symptoms for the treatment of headache.
As nausea and/or vomiting is a common migraine symptom, particularly in children, you could consider an antiemetics to treat it. Prochlorperazine is licensed for the relief of nausea and vomiting associated with migraine attacks. Domperidone is licensed for the relief of nausea and vomiting.
It is important to tell children, their parents and carers about medication overuse headache from acute migraine medication and how to avoid it.
Preventive medication for migraine
Where migraine attacks are frequent, and when they are impacting a child’s life, preventive treatment can be considered and advice from a headache specialist sought. This can be from another GP with a special interest in headache or a neurologist that is a headache specialist, or a paediatrician.
Propranolol hydrochloride and topiramate [unlicensed use] can be used for the prevention of migraine in children. Females of childbearing potential should be warned of the associated risks of taking topiramate during pregnancy, and this should be considered when prescribing it.
Pizotifen is used in the prevention of migraine in adults but its effectiveness in treating migraine in children has not been clearly established.
The effectiveness of preventive migraine treatment should be reviewed after six months as it is often possible to stop its use after a period of treatment.