Diagnosis and Treatment of Childhood Migraine.

opinion statementWhile the diagnosis of migraine in children is generally straightforward, treatment can seem complex with a number of medication choices, many of which are used "off label." Patients with intermittent migraines can often be managed with ibuprofen or naproxen taken as needed. Unfortunately, by the time that children present to our practice, they have often tried these medications without improvement. Triptans are frequently prescribed to these patients with good success. It is important to make the patient aware of the possible associated serotonergic reactions. If the patient is having more than one headache per week or the headaches are prolonged, prophylactic treatment is indicated. In our practice, the overwhelming majority of these patients will be treated with amitriptyline or topiramate. We generally allow side effect tolerability to guide our choice of medication. Cyproheptadine is often used in younger patients as it comes in a liquid form. There is evidence supporting the use of propranolol, though the potential worsening of underlying asthma symptoms may limit its use, and sodium valproate, which must be used with caution in female patients of childbearing age due to significant teratogenicity risks. Other prophylactic treatments with less robust evidence include the antiepileptic drugs gabapentin, zonisamide, and levetiracetam; calcium channel blockers such as verapamil and amlodipine; and the angiotensin receptor blocking agent candasartin (not available in the USA). Almost all patients in our practice are advised to take magnesium supplementation. Magnesium is a supplement with relatively few adverse effects and good evidence for improvement of migraine symptoms. We evaluate lifestyle issues and comorbidities in all our patients. Ignoring these will make successful treatment near impossible. Good sleep, adequate hydration, appropriate diet, and exercise are vitally important. Finally, most of our patients benefit from a psychology evaluation with cognitive behavioral therapy. Stress management and biofeedback are tremendously helpful in improving quality of life in migraineurs.