So, we have discussed migraines and looked at how to diagnose in the pediatric population. Now it’s time to decide how to treat the headache. Just like diagnosing the headaches, it is important to individualize treatment for each child, with the goal being fast relief, no rebound or re-occurrence, with minimal or no side effects to the medications.
When I see a patient who has a history compatible with migraines, I not only have the child and parents keep a headache log, but I spend a lot of time discussing early treatment of the headache. One of the first things you learn in medical school about treating pain is “get ahead of the pain”. This means that you need to be aware of your symptoms and begin therapy earlier than later, as pain that has gone on for some time is much harder to treat. I find that one of the best ways to explain this to a parent and also an older child is to talk about surgery.
When you have a surgical procedure, the anesthesiologist does not wait for you to “wake up” and tell him that it hurts, they have already given you pain medication to “keep ahead of the pain” before they wake you up. If you have ever had surgery you know this to be true.
The same pain principles apply to treating headaches, especially migraines. At the first sign of a migraine, with or without an aura, I usually prescribe an ibuprofen (Motrin, Advil) product. In studies, ibuprofen was more effective for headache relief than acetaminophen. I use a “generous” (10mg/kg/dose) dose and repeat it once in 3 -4 hours if the headache has not resolved.
You do not want to use ibuprofen more often than several times a week or you may find that your child actually gets rebound or overuse headaches. Ibuprofen is available in liquid, chewable and pill form so can be used in a young child with suspected migraines. I also like to use naprosyn (Aleve) in older children who can swallow pills. It too is a non-steroidal anti-inflammatory and is available over the counter.
The most frequently used medications for childhood migraines are called triptans. This class of drugs has been around for more than a decade now, but they are not FDA approved for use in children and adolescents because of the difficulty in designing a study (this is true of many different medications.) Regardless, they are frequently used to treat childhood migraines with good results, tolerability and a good safety profile.
There are many different drugs, with names like Imitrex, Zomig, Maxalt, Frova, and the newest drug Treximet (a combination of a triptan and a non steroidal drug), and all have a similar safety profile.
Once a child has “failed” therapy with an over the counter non-steroidal drug, I typically use these drugs as “rescue” medications. Just like many other medications, each person seems to respond differently, so it may be a bit of trying different medications to see which one works “best” for each migraine sufferer.
When a patient seems to find the best triptan, it is important to start the medication at the earliest onset of a migraine. I also try to help adolescents distinguish between “different” types of headaches, so that they are not using this class of drugs too frequently (max 3 headaches a week). Not every headache is a migraine!
If these medications do not relieve the headaches within 48-72 hours more aggressive therapies need to be used, and preventative treatments and strategies should be considered. There are many studies underway looking at the combined effects of biofeedback therapy and cognitive behavioral therapy in combination with medications. These are discussions that each parent/child should have with their own physician as it relates to their headache frequency and pain level.
That's your daily dose for today. We'll chat again tomorrow.