Migraine headache in children
Migraine is defined by the International Headache Society (IHS) as a recurrent headache that occurs with or without aura and that lasts 4 to 72 hours (2 to 72 hours in children). It is usually unilateral in nature, pulsating in quality, of moderate or severe intensity, and is aggravated by routine physical activity. Nausea, vomiting, photophobia, and phonophobia are common accompanying symptoms. This review focuses on migraine in children younger than 18 years of age.
Focus of the review
The relatively high prevalence of migraine in the paediatric population, together with its attendant educational and social morbidity, mandates the clinical importance of understanding which pharmaceutical agents are available for acute treatment and prophylaxis. The evidence for the benefit of use of the most commonly used agents is presented.
Comments on evidence
There is a paucity of controlled data to support the use of most of the drugs currently recommended or licensed in the management of paediatric migraine. This has led to a tendency to extrapolate data from adult trials or to use anecdotal personal experience when considering any drug for use. The expectations for the success of treatment should take account of the level to which psychological factors are contributing to symptoms. Not all treatments work for every child, and some children will be non-responders even to those medicines for which there is the clearest evidence available from controlled trials to support their use.
Search and appraisal summary
The literature search was carried out from the date of the last search, June 2010, to June 2014. For more information on the electronic databases searched and criteria applied during assessment of studies for potential relevance to the review, please see the Methods section. Searching of electronic databases retrieved 137 studies. After deduplication, 121 records were screened for inclusion in the review. Appraisal of titles and abstracts led to the exclusion of 85 studies and the further review of 36 full publications. Of the 36 full articles evaluated, two systematic reviews and three additional RCTs were included.
When using pharmacological prophylaxis, avoidance of polypharmacy is probably wise. The use of each agent should be reviewed after an initial attempt at prophylaxis of around 3 months. If there has been no improvement in symptoms, consideration should be given to discontinuing it and considering an alternative. The use of long-term prophylaxis in children is probably best avoided if practical. Agents of apparent benefit to individual children should be periodically stopped (perhaps annually, taking careful account of the individual circumstances) and symptomatology reviewed to evaluate whether prophylaxis is still merited.
Substantive changes at this update
5HT1 agonists New RCT added. Categorisation unchanged (beneficial).
Flunarizine New option. Categorised as 'unknown effectiveness'.
Pizotifen One systematic review added. Categorisation unchanged (unknown effectiveness).
Topiramate One systematic review added. Categorisation unchanged (unknown effectiveness).
INTRODUCTION: Diagnosis of migraine headache in children can be difficult as it depends on subjective symptoms; diagnostic criteria are broader than in adults. Migraine occurs in 3% to 10% of children and increases with age up to puberty. Migraine spontaneously remits after puberty in half of children, but if it begins during adolescence it may be more likely to persist throughout adulthood. METHODS AND OUTCOMES: We conducted a systematic review and aimed to answer the following clinical questions: What are the effects of treatments for acute attacks of migraine headache in children? What are the effects of pharmacological prophylaxis for migraine headache in children? We searched: Medline, Embase, The Cochrane Library, and other important databases up to June 2014 (BMJ Clinical Evidence reviews are updated periodically; please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA). RESULTS: Twenty-three studies were included. We performed a GRADE evaluation of the quality of evidence for interventions. CONCLUSIONS: In this systematic review we present information relating to the effectiveness and safety of the following interventions. For acute symptom relief: 5HT1 agonists [such as triptans], non-steroidal anti-inflammatory drugs [NSAIDs], and paracetamol. And, for prophylaxis: beta-blockers, flunarizine, pizotifen, and topiramate.
Rated by doctors in Relevance Newsworthiness General Practice(GP)/Family Practice(FP) ***** ****** Neurology **** **** Pediatrics (General) ****** *****
Rated by doctors in Relevance Newsworthiness General Practice(GP)/Family Practice(FP) **** **** GP/FP/Mental Health ***** ***** Pediatrics (General) ***** ***** Psychiatry ***** ******