Under 12 years of age
1. Ibuprofen: Effective, and available as a liquid, but GI upset is relatively common. A small amount of caffeine may enhance the efficacy
2. Acetaminophen: Well tolerated, safe, but not as effective as ibuprofen. Chewable tablets and liquid are available. Due to its relative safety, acetaminophen is the usual primary abortive used in young children. Adding a small amount of caffeine may enhance efficacy
3. Naproxen (Naprosyn, Aleve): Effective abortive that is nonsedating and is available as a liquid. However, GI side effects are common. (Aleve = OTC = 220 mg)
4. Midrin (generic available) or Prodrin: Midrin capsules: (acetaminophen 325 mg/dichloralphenazone 100 mg/isometheptene 65 mg): ½ or 1 capsule PO q 4 h prn. At younger ages we usually use only ½ at a time. These are very large capsules, but may be taken apart and sprinkled into applesauce or juice. Sedation is common, as is lightheadedness. GI upset, although not common, occurs at times
Prodrin is very similar to Midrin, but without the sedative (no dichloralphenazone), and with a small amount (20 mg) of caffeine. Prodrin tablets may be split in half
5. Caffeine: Used by either itself or with an analgesic, caffeine is useful for tension and migraine headache. In children, soft drinks containing caffeine are helpful. Side effects are minimal when caffeine is used in very limited amounts
6. Triptans: Rizatriptan (Maxalt) is indicated for age 6 and above. Maxalt is available in 5 and 10 mg, in tabs or MLT lozenges. The usual dose would be 5 mg, ½ to start, and increasing dose with advancing age. There is a very low dose sumatriptan nasal spray available (5 mg). I usually begin using the triptans at age 9 or 10
7. (Last resort) Butalbital or other pain medications: Phrenilin (generic available) is butalbital plus acetaminophen, while Fioricet/Esgic adds in caffeine. These should be used in low doses(usually ½ tablet) and not more than 1 day per week
Over 12 years of age (includes the above plus the following)
8. Triptans: Almotriptan (Axert tablets) is FDA-indicated in adolescents. We usually begin with ½ tablet. Maxalt is FDA-indicated age 6 and above. Zomig nasal spray is available in a low dose, 2.5 mg, form (the usual dose in adults is 5 mg). Triptans are generally more effective than analgesics. Contraindicated in complicated migraine and in those with cardiovascular risk factors. Potential side effects include flushing, chest tightness, paresthesias, nausea, and somnolence. More effective when taken early. May be combined with NSAIDs (ibuprofen, naproxen)
9. Prodrin: Acetaminophen, isometheptene, caffeine. Similar to Midrin, but nonsedating. These may be cut in ½, and taken with an NSAID
10. NSAIDs or Cambia: Most NSAIDs may be used with or without caffeine. Cambia is FDA-indicated above age 18, but has been used off-label in adolescents. Cambia is 50 mg, in powdered form, of diclofenac potassium. Cambia may be used with water or apple juice, and the usual dose is ½ or 1 packet every 4 h as needed
11. (Last resort) Butalbital or other pain medications. See above
It is always reasonable to try biofeedback together with simple abortive medications as the first step and attempt to avoid daily preventive medication, if possible. However, with frequent migraines, or for moderate to severe daily headaches, daily preventive medication may be necessary. In order to minimize medications, start at a low dose of a daily preventive and slowly titrate up to reasonable efficacy. Table 3.2 has a more complete list of criteria for the use of preventive medication. Table 3.3 lists first-line preventive medications.
Table 3.2
Criteria for the use of prevention medication
1. The headaches interfere significantly with the child’s functioning socially or at school. The extent of how much the headaches bother the child is a major consideration |
2. Failure of nonpharmacological approaches (watching triggers, biofeedback, etc.) |
3. The child’s and parent’s willingness to utilize daily medication with possible side effects |
4. Willingness of the child and parents to change medication, if necessary |
5. Failure of abortive medication to effectively treat the headaches; continued frequency of headaches, daily or near-daily |
6. In choosing preventives, comorbidities (psychiatric, medical, GI) drive where we go |
Table 3.3
First-line preventive medications for migraine, tension-type, and chronic daily headaches in children and adolescents
Under 12 years of age |
1. Cyproheptadine: Safe, but efficacy is questionable. It is usually well tolerated but fatigue and weight gain may be a problem. Not as useful in children over the age of 11. It may be dosed once a day and is available in liquid form |
2. NSAIDs (Ibuprofen, naproxen): Ibuprofen and naproxen may be utilized as daily preventives or as abortive for both tension and migraine headaches. The lack of sedation renders these very helpful for daily use. GI side effects are relatively common, and when these are used on a long-term basis, regular blood tests for hepatic enzymes and renal function need to be done |
3. Petadolex. (Age 9 + ): A form of the herb butterbur. Good evidence for efficacy in migraine. Widely used in Europe; available for over 35 years and regarded as safe. One tablet (50 mg) daily; may increase to two. Occasional mild GI upset. May be ordered through www.petadolex.com, 1-888-301-1084, or through Amazon.com. Due to carcinogenic concerns (in animal studies, although Petadolex takes off the molecule that is of concern, from the parent compound butterbur), we recommend rotating off of Petadolex for at least 1 month periodically |
4. Magnesium oxide or citrate: Available OTC as tablets or powder. Mild, but effective for some. Safe in this age range. Usual dose is 100–200 mg a day |
5. Feverfew (natural, herbal) is sometimes effective |
6. Topiramate or divalproex: see below: we attempt to avoid these drugs in younger children, but occasionally they are utilized, in low doses |
7. Botox: Off-label under age 18. Botox is the most effective chronic migraine preventive; occasionally Botox has been used under age 12, in low doses |
12 years and older |
1. NSAIDs: occasionally effective for prevention, without the sedative/weight gain side effects of many drugs |
2. Petadolex: See above. Magnesium also is used at all ages |
3. Topiramate: Useful for both migraine and chronic daily headache (CDH), lower doses (e.g., 25–50 mg qHS) are often effective; may be pushed to 100–150 mg daily. Potential side effects include cognitive slowing, paresthesias, decreased appetite/weight loss, and rarely acute glaucoma, renal stones, and acidosis. Cognitive side effects often limit use |
4. Divalproex: Useful for both migraine and CDH, lower doses (e.g., 250 mg) are usually used with some efficacy. May be pushed to 750–1000 mg daily. Potential side effects include GI upset, sedation, weight gain, tremor, dizziness, and alopecia. Blood tests should be performed periodically for hepatic enzymes |
5. Gabapentin: Useful for both migraine and CDH, lower doses (e.g., 100–300 mg BID to TID) are often effective. Potential side effects include dizziness and weight gain, although it is usually very well tolerated by most people, especially at the lower doses recommended |
6. Tricyclic antidepressants: Effective for migraine and CDH. Nortriptyline and amitriptyline are commonly used. Usually well tolerated in low doses and safe for long-term use. Cognitive side effects, dry mouth, drowsiness, dizziness, and weight gain are common. Usual dose of amitriptyline is 10–50 mg daily. Protriptyline does not cause weight gain, but is somewhat less effective. Blood tests should be performed periodically for hepatic enzymes and renal function |
7. Propranolol: Generally well tolerated. Fatigue and decreased exercise tolerance may be a problem. Usual dose is 20–80 mg daily. With doses less than 60 mg qd, BID dosing is required which is inconvenient for children |
8. Verapamil: A calcium channel blocker that is effective for migraine and occasionally CDH. Generally well tolerated, with constipation common. Convenient once per day dosing with the sustained release formulations. Usual dose ranges from 80 mg once a day up to 240 mg ER q day |
9. Botox: Off-label under age 18; botox is only officially indicated for chronic migraine, 18 and above. Botox has been studied in this age range, and is generally regarded as safe and effective. Despite being off-label, Botox has been widely utilized in the 12–18-year age range. The official (age 18 and above) doses are 155 units, given as 31 injections about the head. For younger patients we often use much lower doses, with fewer injections
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