New Guidelines Provide Recommendations, Reveal Gaps in Pediatric Migraine Care

The new guidelines for preventing and treating migraine in children and adolescents provide a framework for evidence-based clinical care. Published in Neurology and Headache last summer, they represent the first significant update since 2004.

As one of the world’s largest centers for studying and treating pediatric and adolescent migraine, Cincinnati Children’s played a significant role in developing the new guidelines. Andrew Hershey, MD, PhD, endowed chair and director of the Division of Neurology, was a senior author and was the first author of the follow-up editorial published in Headache. Here, he reflects on the guidelines’ value for clinical practice and highlights gaps that remain in the understanding of pediatric migraine treatment.

What were some of the report’s key findings? 

In terms of treating individual migraine attacks, the report recommends immediate intervention when symptoms occur, using ibuprofen, triptans such as topiramate, and combination sumatriptan/naproxen. For chronic migraine, first-line treatment should be cognitive behavioral therapy and amitriptyline.

That said, the report acknowledges previous research led by Cincinnati Children’s demonstrating that topiramate and amitriptyline are only as good as placebo when used in children. This is a complex issue that requires further study.

The guidelines focus on the importance of a multidisciplinary, holistic approach to treatment and preventive care. A holistic approach should include counseling on topics such as treatment expectations and the importance of developing healthy diet, exercise and sleep habits. These are vital to help address the comorbid mood disorders that can worsen migraine and delay recovery from attacks.

Are there other ways the guidelines could help patients?

People often attribute pediatric migraine to wearing eyeglasses, food sensitivities and other factors, instead of accepting it as a genetic disease. By providing evidence-based guidelines—things that work—the report may help lower the stigma against migraine as disease and allow more patients to seek effective therapies.

Where do you see opportunities to increase our understanding of migraine prevention and treatment? 

Several new compounds approved for adults are in the process of being approved for children. These include anti-calcitonin gene-related peptide (CGRP) antibodies, as well as CGRP receptor antagonists, sometimes called “gepants.” Another class of medications in the pipeline resembles the older class of triptans, but target the 5HT-1F receptor, sometimes called “ditans.”

Also, some devices that could serve as alternatives to pharmaceuticals are being studied in pediatric patients. These include some electrical and magnetic-based stimulators.

The Headache Center at Cincinnati Children’s has received funding from the National Institutes of Health every year since 2003. Thanks in part to this funding, and our partnerships with a number of pharmaceutical companies, we can make significant contributions in this important area of research. It’s an exciting time in migraine research, and I expect that in the next few years there will be a lot more opportunities to treat children and adolescents with individually effective medications and devices.

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