New drug-therapy guidelines for kids' migraines (search) stress tried-and-true medicines — and find newer drugs unproven.
The guidelines say ibuprofen (search) (Advil and Motrin, for example) and acetaminophen (search) (Tylenol) are safe and effective for acute migraine pain in kids aged 6 years and older. Teens may also benefit from Imitrex nasal spray.
What about newer drugs that work for adult migraines? There's no proof they work in kids, the guidelines say. Similarly, the guidelines offer no easy solution to preventing migraines. Only one drug is proven effective. That drug, Sibelium, is not available in the U.S.
What gives? The problem is that pediatric clinical trials of these drugs are few and far between. And those that have been done often suffer from poor design, says Donald Lewis, MD, lead author of the guidelines. Lewis is professor of pediatrics and neurology at Eastern Virginia Medical School and a child neurologist at Children's Hospital of the King's Daughters in Norfolk, Va.
"This is one of those unfortunate areas where a very common problem has been understudied," Lewis tells WebMD. "There is a lot of denial, among families and among clinicians, that children do get migraines. We need more clinical trials to see how these medicines work in children. ... One of the themes here is that initial trials have failed. More intense and innovative research needs to be done."
The guidelines, endorsed by the American Academy of Pediatrics and the American Headache Society, come from the American Academy of Neurology and are based on a review of published studies. They appear in the Dec. 28 issue of Neurology.
Good News: Nondrug Treatment Works
Not all kids need drugs for successful migraine treatment and prevention, Lewis stresses.
"The treatment for many problems in children is not just drugs. It is often a lifestyle change," Lewis says. "Biobehavioral migraine treatment is a whole-package approach to managing these children. For every patient, treatment has to be individually tailored. We may not commit a child to daily medication right off the bat."
Behavioral treatments work for adults. And they work even better for kids, says psychiatry professor Donald B. Penzien, PhD, director of the University of Mississippi's head pain center.
"The happy news is that the outcomes for behavioral migraine treatments are really quite strong," Penzien tells WebMD. "They not only treat pain but have the added bonus of helping with the family and school disruption that goes with headache."
The key to behavioral treatments for migraine is a healthy lifestyle, Lewis says.
"Teens, for example, often have chaotic sleep patterns. They tend to skip breakfast, get too much caffeine either in sodas or lattes, and often experience a lot of stressors in their lives," he says. "So we make sure they eat right and get exercise — that is critical. I mandate 20-30 minutes of exercise every single day. We do a lifestyle change, keep a migraine calendar, and then we can see whether further treatment is needed."
Lewis and Penzien agree that no single approach works for every child. But many approaches that work for adults can easily be adapted for children.
"The same treatments for adults that we call behavioral — relaxation, biofeedback, stress management, cognitive-behavioral psychotherapy — with special adaptations can be made for children," Penzien says. "The self-regulation training therapies – the relaxation, the biofeedback — tend to work much better for kids. They take to it like a duck to water."
When Drugs Are Needed
Despite behavioral therapy, children may still have migraines from time to time. When they do, drugs can help.
"If in spite of lifestyle modification a child is having one or two disabling headaches a month, we try to treat them," Lewis says.
Penzien says headache specialists are wary of as-yet-unknown long-term effects of migraine drugs on children.
"We tend to treat conservatively with the medications — not because we are anti-medication, but because the potential for side effects are strong with developing nervous systems," Penzien says. "Even though we don't know there is a problem with the newer drugs, it makes you nervous. The truth is that most children are using a combination of drugs and behavioral therapy. Usually the safer analgesics over the counter can be quite helpful."
The biggest problem facing children with migraines is not that there are few proven treatments. The problem, Lewis says, is that parents and doctors are slow to recognize serious headaches in children.
"The first step is to get it recognized that a child suffers from migraine headaches," Lewis says. "There is a gross under-recognition of the problem in children. Many parents don't know that children can have migraines. Yet up to 5 percent of elementary school children and 15 percent of high school children do."
By Daniel J. DeNoon, reviewed by Brunilda Nazario, MD
SOURCES: Lewis, D. Neurology, Dec. 28, 2004; vol 63: pp 2215-2224. Donald Lewis, MD, professor of pediatrics and neurology, Eastern Virginia Medical School; child neurologist, Children's Hospital of the King's Daughters, Norfolk, Va. Donald B. Penzien, PhD, director of head pain center and professor of psychiatry, University of Mississippi Medical Center, Jackson.