Treatments for when symptoms are acting up
What patients and families need to know about acute treatments
Non-medication options
There
☆ Editor’s Note: The acute treatment of migraine is a fine balancing act. If one waits too long, the attack becomes harder to treat. If one overreacts each time, there is the possibility of medication overuse. For patients with episodic headaches, prompt attention with medication and rest is the answer. For patients with chronic headache, it is more challenging knowing how best to treat headache exacerbations. This chapter deals primarily with the approach to the youngster with an acute attack who does not have daily headache. Incorporation of behavioral interventions can be helpful in deescalating the attack.
are non-medication strategies to stop or reduce the severity of symptoms associated with a migraine attack. The goal is to get back to normal functioning while minimizing the risk of side effects. Drinking water, eating something healthy, resting, and addressing triggers can be helpful. These things may prevent the symptoms from escalating. Please see the chapters on Self-Care strategies. Natural treatments such as aromatherapy or ginger can be used to relieve nausea. Patients commonly ask if acupuncture, chiropractic, or massage could be helpful. Please refer to the chapter on Nonpharmaceutical Options for more information. The field of “neuromodulation” devices is growing, and can provide beneficial non-pharmacologic treatment of migraine associated symptoms. Please see the chapter on Devices.Medication options
Headache pain is a common and disabling symptom in migraine children. Acute treatment refers to medication which can be given to relieve the pain and discomfort associated with a migraine attack. These medications can help lessen or stop a migrane from progressing. Ideally, they can be given whether the child or adolescent is at home, at school or on the go as they are most helpful when taken earlier in a migraine, before the pain is severe. First line treatments involve over the counter medications such as ibuprofen, naproxen, and acetaminophen. Ibuprofen or other medications in the same category have been found to be more effective than acetaminophen and are more commonly used. In young children, dosing is based on a child’s weight, and can be found on the medication label. A dose which is too low may not help your child’s pain and may require more frequent dosing. If the medication is given too frequently (typically ≥ 15 days per month), it may lead to medication overuse headache. This phenomenon can cause an increase in headaches, decreased effectiveness of medication, and depending on the medication, result in side effects such as stomach upset or liver abnormalities.
Some children also experience other symptoms such as nausea or vomiting with their migraine attacks. These symptoms contribute to discomfort and place them at risk for dehydration. If nausea is often a bothersome symptom, talk to your child’s doctor about prescribing a nausea medication such as ondansetron.
Sometimes over the counter medications together with rest and hydration may not be helpful for your child’s pain. In these cases, your child’s doctor may be able to prescribe a migraine specific medication. Triptans are medications developed to stop pain associated with migraines. There are several different triptans, and depending on the medication, are available in dissolving and non-dissolving tablet, nasal spray, and injectable forms. Several of them are approved for use in the pediatric and adolescent population and can take effect in as little as half an hour. They are safe to use together with various other acute medications and often work better when taken with ibuprofen or other medications in the same class. If a medication is tried for one migraine attack and is not helpful, it is recommended to retry the medication for at least 2–3 migranes to fully assess how helpful it is. For acute medications that are well tolerated, families are encouraged to discuss with the school and their doctor that these medications should be available for administration at school if needed.
We hope that this information gives you the tools to help your child through their migraines. It is important to remain in communication with your child’s doctor, as sometimes it takes a few trials to find the best acute treatment regimen for your child’s migraine symptoms.
What primary care providers need to know about acute medication treatments
The majority of children and adolescents with migraine will be evaluated and treated first by their primary care provider (PCP). Many communities have significant waiting time for child neurology/headache specialist consultation, and thus there is a significant opportunity for PCPs to address their patient’s pain in the interim before it becomes a more chronic and disabling disorder.
A commonly encountered scenario is a young, otherwise healthy teen with worsening migraine control, provoked by the onset of a new school year or viral upper respiratory infection. Once it is determined the issue is a primary and not secondary headache, it is not unusual for patients to be instructed to utilize acetaminophen and/or ibuprofen until the headache pattern improves. Unfortunately, when simple analgesics are overused, some patients may develop medication overuse headache (MOH). MOH is diagnosed when a patient with a primary headache disorder develops headache occurring at least 15 days per month for over 3 months in the setting of an overused acute medication. It is the author’s opinion that it may take less than 3 months for this issue to develop in some cases. Approximately one third to half of adolescents with chronic migraine have MOH. Table 1 illustrates common classes of medications that result in medication overuse headache.
| Drug class | Frequency resulting in medication Overuse Headache (in days) |
|---|---|
| Simple analgesics (e.g., acetaminophen, ibuprofen) | ≥ 15 |
| Triptans (e.g., sumatriptan, rizatriptan) | ≥ 10 |
| Opioids a (e.g., oxycodone, hydrocodone) | ≥ 10 |
| Combination analgesics (e.g., acetaminophen with butalbital or codeine) with adjuvants (e.g., caffeine) | ≥ 10 |
The potential consequences of MOH are increased headache frequency, reduced efficacy of acute and preventive medications, dependence and tolerance to the overused medication, and side effects such as gastrointestinal upset or liver dysfunction depending on the medication. The chance for developing medication overuse headache can be mitigated by preemptively educating patients and their families on the potential for MOH, scheduling close follow-up and not prescribing too many doses and refills for medications with a strong potential for this condition.
Acute treatment options
Many patients during a severe migraine prefer to rest in a dark, cool, and quiet room until the intensity subsides. The goal of acute treatment is to provide rapid relief of migraine symptoms with little to no side effects. Treatment is dictated by the features and severity of the attack. Treating early, rather than later in an attack, may expedite the resolution of symptoms. For example, if a patient has a severe migraine and is already having emesis, an oral treatment such as an over the counter analgesic may have little to no efficacy. The clinician should guide the patient to treat this level of migraine more aggressively at onset rather than treating gradually or stepwise and allowing the migraine to intensify.
Acute treatment options include simple analgesics such as acetaminophen and non-steroidal anti-inflammatory drugs (NSAIDs) as well as triptans and antiemetics. In one of the few randomized double-blinded placebo-controlled trials for pediatric acute migraine treatment, ibuprofen (OR 2.9, 95% CI 1.0–8.1) was more likely than acetaminophen (OR 2.2, 95% CI 1.1–4.0), which was still more likely than placebo to reduce headache severity by at least 2 points on a 5-point scale. The author prefers the use of longer acting NSAIDs such as naproxen, with limited evidence suggesting it may reduce the likelihood of transformation from episodic to chronic migraine. It also has been studied with concurrent triptan use for acute migraine and appears combined treatment provides more benefit use than using either treatment alone. The author finds naproxen to be particularly helpful when used as short term “bridge therapy” when headache frequency flares in the setting of typical exacerbating triggers such as viral illness, mild head injury, or perimenstrually.
Triptans were the first class of medications designed specifically for acute migraine treatment. Triptans are 5-hydroxytryptamine (5-HT 1B/1D ) receptor agonists. They have been shown to reduce levels of the nociceptive neuropeptide calcitonin gene-related peptide (CGRP), which as discussed in the prior chapter Pathophysiology of Migraine , becomes elevated during a migraine attack. Seven triptans are on the market; however, only four have Food and Drug Administration (FDA) approval for pediatric migraine use. For patients aged 12 years and older, FDA approved triptans include sumatriptan/naproxen, zolmitriptan nasal spray, and almotriptan while rizatriptan is approved for patients aged 6–17 years. Triptans are contraindicated in patients with a history of cardiovascular disease or cardiac accessory conduction pathway disorders. Triptans are per the FDA still contraindicated for use with hemiplegic aura or migraine with brainstem aura. The 2019 American Academy of Neurology pediatric acute treatment of migraine guidelines emphasize this concern was based on an antiquated understanding of migraine pathophysiology, suggesting it may be safe for use in these patients. The counter argument states that these drugs were never tested for these conditions so they should not be used. Triptans are generally well tolerated and should be offered to pediatric and adolescent patients with migraine. Oral triptans should be considered for most patients except those with a fairly rapid onset of peak migraine pain or emesis. In these cases, the nasal sprays or subcutaneous injections have a quicker onset of action and avoid the GI route for absorption.
What a headache specialist needs to know about acute medication treatments
Treatment of acute headache symptoms is multi-factorial. A headache specialist may emphasize hydration and rest, in addition to providing anti-emetics if nausea is present and other migraine rescue medication options. The most frequently studied and used medications for the acute treatment of headaches include NSAIDs, triptans, and dopamine receptor antagonists. The role of NSAIDs was discussed in the previous section on treatment of headache by the primary care provider. Anti-emetics will not be discussed in detail, except as a potential benefit of dopamine receptor antagonists.
Triptans
By the time a patient presents to a headache specialist’s office, they have most likely tried NSAIDs and possibly one or more triptans. Triptans are serotonin 5HT 1B,1D receptor agonists that block the release of vasoactive peptides at the trigeminal nucleus caudalis. While triptans do not shorten aura duration, in one-third of people they can curtail a migraine attack within 2 hours of administration. They are most effective if taken when the pain is still mild, which tends to be earlier in attack. Triptans are, however, contraindicated in patients with cardiovascular disease, uncontrolled hypertension, stroke, and in pregnancy. The low incidence of these contraindications in the pediatric and adolescent population make triptans a suitable acute therapy option.
There are seven triptans; three triptans and a fourth triptan/NSAID combination have been approved by the Food and Drug Administration for acute migraine therapy in the pediatric population. These approved triptans include ( Table 2 ) almotriptan in 12- to 17-year olds (6.25 or 12.5 mg oral), rizatriptan in 6- to 17-year olds (5 mg MLT for 20–39 kg, 10 mg MLT for ≥ 40 kg), zolmitriptan NS in ages 12–17 years (2.5 or 5 mg), and sumatriptan 10 mg combined with naproxen 60 mg in ages 12–17 years (with an option to increase dosage to 85 mg sumatriptan combined with 500 mg naproxen). Other triptans which do not have the pediatric and adolescent FDA approval, but may still be effective when used off-label, include eletriptan, naratriptan, and frovatriptan. The most effective triptans include rizatriptan 10 mg, eletriptan 80 mg, and almotriptan 12.5 mg.
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