AAN 2019 migraine treatment guidelines for children and adolescents

M3 India Newsdesk Nov 27, 2019

The American Academy of Neurology (AAN) 2019 migraine treatment guideline for children and adolescents provides recommendations for migraine prevention using pharmacologic treatment with or without cognitive behavioural therapy (CBT) in the paediatric population.


As per the American Academy of Neurology (AAN), a majority of randomized controlled trials studying the efficacy of preventive medications for paediatric migraine fail to demonstrate superiority to placebo. Prevention strategies for migraine in children should include counselling on lifestyle and behavioural factors that influence headache frequency and assessment and management of comorbid disorders associated with headache persistence.

Migraine is commonly observed in children and adolescents. While most children benefit from acute migraine treatments along with behavioural and lifestyle changes, additional migraine prevention strategies should be considered in cases where headaches occur with sufficient frequency and severity and result in migraine-related disability.


Counselling and education for children and adolescents with migraine and their families

Family history and female sex are high risk factors for the development of migraine that persists into adulthood. Disease prevention should be the main goal of migraine management.

A number of behavioural factors can influence the frequency of headaches in migraine. Recurrent headache in adolescents have been associated with the following factors:

  • Being overweight
  • Caffeine and alcohol use
  • Lack of physical activity
  • Poor sleep habits
  • Tobacco exposure

Depression is also related with higher headache disability in adolescents.

Identifying and avoiding the causative factor can help reduce the frequency of migraines; for example reducing weight can lead to headache reduction in children who are overweight.

Recommendations

  • Clinicians should counsel patients and families that lifestyle and behavioural factors may influence headache frequency
  • Clinicians should educate patients and families to identify and modify migraine contributors that are potentially modifiable

The prevalence of headache for more than 6 days in a month and medication overuse are well known risk factors for progression to chronic migraine in adults, and thus, preventive treatment is suggested in these populations.

Although there is no study which covers the association between frequent headache, medication overuse, and progression to chronic migraine in paediatric populations, based on the association found in adults, it is hypothesised that similar relationships may occur in paediatric populations too.

  • Clinicians should discuss the potential role of preventive treatments in children and adolescents with frequent headache or migraine-related disability or both
  • Clinicians should discuss the potential role of preventive treatments in children and adolescents with medication overuse

Starting preventive treatment

As per the guideline panel, the majority of randomised controlled trials that studied the efficacy of preventive medications for paediatric migraine fail to demonstrate superiority to placebo (with studies demonstrating a high response to placebo).

Topiramate: Topiramate has been found to decrease the number of days with headache and the frequency of migraine attacks in paediatric population; however, there is lack of evidence for 50% reduction in migraine frequency or headache days, and reduction in migraine-related disability with the use of topiramate.

Propranolol: The benefit of propranolol in 50% reduction in headache frequency in paediatric migraine patients is well established in clinical studies.

Amitriptyline: Children administered amitriptyline in combination with CBT are more likely to experience a decreased headache frequency. These patients are also found to have more than a 50% reduction in headache frequency and a decreased migraine-associated disability. It should be noted that amitriptyline carries a Food and Drug Administration (FDA) black box warning regarding risk of suicidal thoughts and behaviour especially in children, adolescents, and young adults. The panel suggest that it is possible that CBT alone is effective in migraine prevention, and individual barriers to access may exist.

Recommendations

  • Clinicians should inform patients and caregivers that in clinical trials of preventive treatments for paediatric migraine, many children and adolescents who received placebo improved and the majority of preventive medications were not superior to placebo
  • Acknowledging the limitations of currently available evidence, clinicians should engage in shared decision-making regarding the use of short-term treatment trials (a minimum of 2 months) for those who could benefit from preventive treatment
  • Clinicians should discuss the evidence for amitriptyline combined with CBT for migraine prevention; inform patients of the potential side effects of amitriptyline including risk of suicide, and work with families to identify providers who can offer this type of treatment
  • Clinicians should discuss the evidence for topiramate for migraine prevention in children and adolescents and its side effects in this population
  • Clinicians should discuss the evidence for propranolol for migraine prevention and its side effects in children and adolescents

Counselling for patients of childbearing potential

Topiramate and valproate are well-known teratogenic drugs; additionally, prenatal exposure to valproate may lead to developmental disorders in the offspring. Topiramate at higher doses are also known to interact with oral combined hormonal contraceptives.

Preconceptional folic acid supplementation is recommended for childbearing women, as it reduces the risk of major congenital malformations.

Recommendations

  • Clinicians must consider the teratogenic effect of topiramate and valproate in their choice of migraine prevention therapy recommendations to patients of childbearing potential
  • Clinicians who offer topiramate or valproate for migraine prevention to patients of childbearing potential must counsel these patients about potential effects on fetal/childhood development
  • Clinicians who prescribe topiramate for migraine prevention to patients of childbearing potential must counsel these patients about the potential of this medication to decrease the efficacy of oral combined hormonal contraceptives, particularly at doses over 200 mg daily
  • Clinicians who prescribe topiramate or valproate for migraine prevention to patients of childbearing potential should counsel patients to discuss optimal contraception methods with their health care provider during treatment
  • Clinicians must recommend daily folic acid supplementation to patients of childbearing potential who take topiramate or valproate

Monitoring and stopping medication

As migraine is a chronic disorder associated with spontaneous remissions and relapses, a lot of variability is observed in the information regarding the exact duration for which the preventive treatment should be continued; same holds true for data regarding the risk of relapse after discontinuation.

Recommendations

  • Clinicians must periodically monitor medication effectiveness and adverse events when prescribing migraine preventive treatments
  • Clinicians should counsel patients and families about risks and benefits of stopping preventive medication once good migraine control is established

Mental illness in children and adolescents with migraine

There is a lack of consistent evidence for the association of mental illness in children and adolescents with migraine. A recent systematic review assessed the prognostic factors for recurrent headaches in children and adolescents. As per the review, there is high evidence that children with negative emotional states, manifesting through anxiety, depression, or mental distress, are not at greater risk of developing recurrent headache; however, it found moderate-quality evidence that suggested the presence of comorbid negative emotional states in children with headache is associated with an increased risk of headache persistence in those who already experience recurrent headaches.

Recommendations

  • Children and adolescents with migraine should be screened for mood and anxiety disorders because of the increased risk of headache persistence
  • In children and adolescents with migraine who have comorbid mood and anxiety disorders, clinicians should discuss management options for these disorders

 

Disclaimer- The views and opinions expressed in this article are those of the author's and do not necessarily reflect the official policy or position of M3 India.

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