By Sue Hubbard, M.D.
We discussed migraine headaches and how they're diagnosed in children. Now it's time to decide how to treat a migraine. Just as with diagnosing these headaches, it's important to individualize treatment for each child, with the goal being fast relief, no rebound or re-occurrence, and minimal or no side effects to medication.
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 also 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 to "get ahead" of it. This means you need to be aware of your symptoms and begin therapy early, as pain that's gone on for some time is much harder to treat.
I find that one of the best ways to explain this to a parents and older children is to talk about surgery. When you have a surgical procedure, the anesthesiologist doesn't wait for you to "wake up" and tell him that it hurts; he's already given you medication to "keep ahead of the pain" before waking you up. If you've 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 don't want to use ibuprofen more often than several times a week or you may find 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 these meds 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, 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 you may need to try different medications to see which one works best for each migraine patient.
When a patient seems to find the best triptan, it's 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 they're not using this class of drugs too frequently (max 3 headaches a week). Not every headache is a migraine!
If these medications don't 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 physician as it relates to their headache frequency and pain level.
Dr. Sue Hubbard is a nationally known pediatrician and co-host of "The Kid's Doctor" radio show. Submit questions at www.kidsdr.com.
This was printed in the September 8, 2013 - September 21, 2013 Edition