Pharmacotherapy for acute migraines in children and adolescents

ABSTRACT

Introduction: Migraine is increasingly recognized as an extremely burdensome and disabling disorder in both children and adolescents. A proper treatment plan is needed to improve the quality of life of both children and families as well as to minimize the risk of disease progression.

Areas covered: This review focuses on the current pharmacotherapy for acute migraine in pediatric populations, taking into account specific considerations for those drugs tested in randomized, placebo-controlled trials (RCTs).

Expert opinion: A large number of RCTs have documented the efficacy, tolerability, and safety of different compounds. Triptans appears more effective than placebo but results are variable and inconsistent. Almotriptan and rizatriptan are effective as oral formulations, as well as sumatriptan and zolmitriptan as both oral and nasal spray formulations. Adding non-steroidal anti-inflammatory drugs (NSAIDs) reinforces triptan’s effectiveness. Furthermore, small RCTs have documented both the efficacy of ibuprofen and the ineffectiveness of acetaminophen. Naproxen, ketoprofen, diclofenac, and indomethacin – NSAIDs effective in acute migraines in adults – should be tested also in pediatric subjects. Furthermore, the authors suggest that dopamine receptor antagonists should be considered in cases of severe migraines. Lastly, better designed RCTs are needed to fine-tune current therapeutic resources.

KEYWORDS:

• Pediatric migraine
• children
• adolescents
• acute migraine
• pharmacotherapy
• triptans
• NSAIDs

Article highlights

• Twenty-four RCTs over the last two decades have documented the efficacy, tolerability, and safety of different medicines in the acute treatment of migraines.

• Among common analgesics, limited scientific evidence supports the use of ibuprofen alone.

• Triptans as a class are effective and well tolerated but results of clinical trials are variable and inconsistent.

• Almotriptan, rizatriptan, and sumatriptan/naproxen in combination are effective as oral formulations, while sumatriptan alone and zolmitriptan are effective as nasal sprays.

• Naproxen, ketoprofen, diclofenac, and indomethacin – NSAIDs effective in acute migraine in adults – should be tested in specifically designed RCTs in pediatric migraine sufferers.

• Better designed RCTs are needed to fine-tune our currently available therapeutic resources, stratifying patients by age, gender, and pubertal status, defining the drug dose based on body weight, using a placebo challenge and more strict end points.

This box summarizes key points contained in the article.

Acknowledgments

The authors thank Professor Paul Rizzoli for the helpful discussion and supervision.

Declaration of interest

P Barbanti has received consultancy and advisory fees from Allergan, Bayer Healthcare, electroCore and Visupharma as well as advisory fees from Abbott, Merck & Co, Teva and Novartis. L Grazzi, meanwhile, has received consultancy and advisory fees from Allergan and electroCore. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Additional information

Funding

The authors are supported by the Italian Ministry of Health for Institutional Research.