TABLE 9–5.
Recommendations of the AAN and AHS 2019 Practice Guideline Update: Pharmacologic Treatment for Pediatric Migraine Preventiona
| Counseling and education for children and adolescents with migraine and their families |
| ◆ Clinicians should counsel patients and families that lifestyle and behavioral factors influence headache frequency |
| ◆ Clinicians should educate patients and families to identify and modify migraine contributors that are potentially modifiable (ie, being overweight, caffeine and alcohol use, lack of physical activity, poor sleep habits, tobacco exposure, depression) |
| ◆ Clinicians should discuss the potential role of preventive treatments in children and adolescents with frequent headache (defined in trials as a minimum of 4 headache days per month and three to four migraine attacks per month for at least 3 months) or migraine-related disability (PedMIDAS score >30) or both |
| ◆ Clinicians should discuss the potential role of preventive treatments in children and adolescents in medication overuse (taking triptans, ergotamines, opioids, and combination analgesics >9 days in a month or taking over-the-counter analgesics on >14 days in a month) |
| Starting preventive treatment |
| ◆ Clinicians should inform patients and caregivers that in clinical trials of preventive treatments for pediatric migraine, placebo was effective and the majority of preventive medications were not superior to placebo |
| ◆ Acknowledging the limitations of currently available evidence, clinicians should engage in shared decision making regarding the use of short-term trials (a minimum of 2 months) for those who could benefit from preventive treatment |
| ◆ Clinicians should discuss the evidence for amitriptyline combined with cognitive-behavioral therapy for migraine prevention, inform them of the potential side effects of amitriptyline including risk of suicide, and work with families to identify providers who can offer this type of treatment |
| ◆ Clinicians should discuss the evidence for topiramate for pediatric migraine prevention and its side effects |
| ◆ Clinicians should discuss the evidence for propranolol for pediatric migraine prevention and its side effects |
| Counseling for patients of childbearing potential |
| ◆ Clinicians must consider the teratogenic effect of topiramate and valproate in their choice of migraine prevention therapy recommendations to patients of childbearing potential |
| ◆ Clinicians who offer topiramate or valproate for migraine prevention to patients of childbearing potential must counsel these patients about potential effects on fetal/childhood development |
| ◆ Clinicians who prescribe topiramate for migraine prevention to patients of childbearing potential must counsel these patients about the potential of this medication to decrease the efficacy of oral combined hormonal contraceptives, particularly at doses over 200 mg daily |
| ◆ Clinicians who prescribe topiramate or valproate for migraine prevention to patients of childbearing potential should counsel patients to discuss optimal contraception methods with their health care provider during treatment |
| ◆ Clinicians must recommend daily folic acid supplementation to patients of childbearing potential who take topiramate or valproate |
| Monitoring and stopping medication |
| ◆ Clinicians must periodically monitor medication effectiveness and adverse events when prescribing migraine preventive treatment |
| ◆ Clinicians should counsel patients and families about the risks and benefits of stopping preventive medication once good migraine control is establishedb |
| Mental illness in children and adolescents with migraine |
| ◆ Children and adolescents with migraine should be screened for mood and anxiety disorders because of the increased risk of headache persistence |
| ◆ In children and adolescents with migraine who have comorbid mood and anxiety disorders, clinicians should discuss management options for these disorders |
AAN = American Academy of Neurology; AHS = American Headache Society; PedMIDAS = Pediatric Migraine Disability Assessment.
a
Data from Oskoui M, et al, Neurology.9
b
“Good migraine control” is not well defined.