AAN Guidelines on medications for acute treatment and prevention of migraine in children and adolescents

Reference

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;93(11):487-499. 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;93(11):500-509

Synopsis

The American Academy of Neurology (AAN) convened a "multidisciplinary panel" consisting of AAN members and patient representatives. The guideline process was guided by a systematic review of multiple databases and used randomized controlled trials that included children or adolescents (up to 17 years of age) with migraines. They developed two sets of guidelines, one for the acute management and one for the prevention of migraine. They used similar guideline development methods, restricting their search to studies published since the release of AAN guidelines in 2004. The authors evaluated the risk of bias for each study. For acute management, the panel identified six studies that evaluated several outcomes. For pain relief 30 minutes after treatment, the panel was fairly pessimistic-no evidence that triptans in any dose or delivery model really help children and reported that sumatriptan 20 mg as a nasal spray was only slightly effective in adolescents. For partial pain relief at one hour, the panel reported that triptan nasal sprays - zolmitriptan 5 mg and sumatriptan 10 mg and 20 mg - were slightly more effective than placebo in adolescents. For complete pain relief 60 minutes later, the panel found that adolescents receiving zolmitriptan 5 mg nasal spray did better than placebo. For complete relief two hours later, the panel reported the combination of sumatriptan plus naproxen in various doses and zolmitriptan 5 mg nasal spray were all more effective than placebo and that ibuprofen and sumatriptan 20 mg nasal spray were likely to be more effective than placebo. Finally, acetaminophen and ibuprofen were found to be slightly better than placebo in reducing pain two hours after treatment but not in removing pain altogether. They also looked at migraine-associated symptoms such as nausea, vomiting, photophobia and phonophobia. With the exception of photo- or phono-phobia where various triptans were helpful in adolescents, other symptoms are not likely to be improved. For migraine prevention, the panel found 15 relevant randomized trials. To decrease the frequency of migraines, the panel found that amitriptyline plus cognitive behavioral therapy was likely the most effective while topirimate and cinnarizine were moderately effective. They found insufficient data for valproate, amitriptyline monotherapy, flunarizine nimodipine, or onabotulinumtoxin A. They also reported that cinnarizine was better than placebo in reducing the severity of headaches. Finally, to achieve a 50% reduction in headache frequency, the panel found that amitriptyline plus cognitive behavioral therapy was the most likely to be effective and that propranolol and cinnarizine were each slightly better than placebo.