Migraine headache in children

The initial assessment should provide an insight into the level of patient and family anxiety that might be contributing to symptom perception, and should facilitate the setting of realistic expectations of management.

Advise patients and families that lifestyle and behavioural factors (e.g., poor sleep habits, missing meals, being overweight, lack of physical activity) may affect headache frequency. Work with them to identify and address any such factors. Establishing whether stress is a contributory factor is also important, and steps to reduce stress should be taken.[5]Oskoui M, Pringsheim T, Billinghurst L, et al. Practice guideline update summary: pharmacologic treatment for pediatric migraine prevention. Report of the Guideline Development, Dissemination, and Implementation Subcommittee of the American Academy of Neurology and the American Headache Society. Neurology. 2019 Sep 10;93(11):500-9. https://www.neurology.org/doi/10.1212/WNL.0000000000008105 http://www.ncbi.nlm.nih.gov/pubmed/31413170?tool=bestpractice.com [27]Seng EK, Martin PR, Houle TT. Lifestyle factors and migraine. Lancet Neurol. 2022 Oct;21(10):911-21. http://www.ncbi.nlm.nih.gov/pubmed/36115363?tool=bestpractice.com

Before starting treatment, discuss with the patient and family what will constitute success from their perspective: for example, reduction in school absence, number of symptom-free days per month.

Also advise the patient and family of the following:[26]Oskoui M, Pringsheim T, Holler-Managan Y, et al. Practice guideline update summary: acute treatment of migraine in children and adolescents. Report of the Guideline Development, Dissemination, and Implementation Subcommittee of the American Academy of Neurology and the American Headache Society. Neurology. 2019 Sep 10;93(11):487-99. https://www.neurology.org/doi/10.1212/WNL.0000000000008095 http://www.ncbi.nlm.nih.gov/pubmed/31413171?tool=bestpractice.com [64]National Institute for Health and Care Excellence. Headaches in over 12s: diagnosis and management. Dec 2021 [internet publication]. https://www.nice.org.uk/guidance/cg150

• Do not delay treatment. To be as effective as possible, it is important that treatment is started at the first signs of a migraine attack, before pain is severe. Delaying treatment may result in drugs being less effective, with a greater likelihood of nausea developing and the attack lasting longer than it might otherwise.

• Avoid any likely triggers as far as possible. These may include particular foods (e.g., chocolate, cheese, citrus fruits, tomatoes), high caffeine intake, and specific odours.

• Keeping a headache diary may be helpful to record the frequency, duration, and severity of headaches and to monitor response to treatments.

• Excessive use of drugs can result in medication-overuse headache.

Patients of childbearing potential

• Inform patients with the potential to become pregnant about the effects of drugs on the efficacy of oral contraceptives and on fetal/childhood development.[26]Oskoui M, Pringsheim T, Holler-Managan Y, et al. Practice guideline update summary: acute treatment of migraine in children and adolescents. Report of the Guideline Development, Dissemination, and Implementation Subcommittee of the American Academy of Neurology and the American Headache Society. Neurology. 2019 Sep 10;93(11):487-99. https://www.neurology.org/doi/10.1212/WNL.0000000000008095 http://www.ncbi.nlm.nih.gov/pubmed/31413171?tool=bestpractice.com [64]National Institute for Health and Care Excellence. Headaches in over 12s: diagnosis and management. Dec 2021 [internet publication]. https://www.nice.org.uk/guidance/cg150

• Topiramate exposure during pregnancy is associated with child neurodevelopmental disorders and congenital malformations.[35]Bjørk MH, Zoega H, Leinonen MK, et al. Association of prenatal exposure to antiseizure medication with risk of autism and intellectual disability. JAMA Neurol. 2022 Jul 1;79(7):672-81. https://jamanetwork.com/journals/jamaneurology/fullarticle/2793003 http://www.ncbi.nlm.nih.gov/pubmed/35639399?tool=bestpractice.com [36]Marmura MJ. Safety of topiramate for treating migraines. Expert Opin Drug Saf. 2014 Sep;13(9):1241-7. http://www.ncbi.nlm.nih.gov/pubmed/25096056?tool=bestpractice.com ​ In some countries, topiramate is contraindicated in pregnancy and in women of childbearing age unless the conditions of a pregnancy prevention programme are fulfilled to ensure that women of childbearing potential: are using highly effective contraception; have a pregnancy test to exclude pregnancy before starting topiramate; and are aware of the risks associated with use of the drug.