The evidence from randomized and clinical controlled trials concerning efficacy and tolerability of symptomatic treatment of migraine in children was reviewed by search of databases from inception to June 2004 at Erasmus Medical Centre, Rotterdam, and Vlietland Hospital, Vlaardingen, The Netherlands. In a total of 10 trials reviewed, 1575 patients kept headache diaries, and those whose headaches (HA) had declined by >50% were considered improved. Compared to placebo, acetaminophen (15 mg/kg) and ibuprofen (10 mg/kg) significantly reduced HAs at 1 and 2 hours after intake, and adverse effects were minor. Nasal-spray sumatriptan was more effective than placebo in reduction of HAs, but side effects, especially bad taste in 26%, were significantly more frequent. Intravenous prochlorperazine was more effective than intravenous ketorolac in the reduction of symptoms at 1 hour after injection. The effect of oral dihydroergotamine was not different from placebo. The authors conclude that acetaminophen, ibuprofen, and nasal-spray sumatriptan are all effective symptomatic treatments for acute migraine in children, but future studies should include quality of life and missed school days as measures of outcome in addition to HA reduction. [1]

COMMENT. The results of acute and prophylactic management of migraine in children, using data from published reports, have also been reviewed by practice committees of the American Academy of Neurology and Child Neurology Society (Ped Neur Briefs Jan 2005;19:3-4) [2]. Similar to the Netherlands experience, researchers in the United States found ibuprofen effective and acetaminophen, probably effective for acute treatment of migraine in children. Sumatriptan nasal spray was effective and was recommended for use in adolescents. Except for the calcium channel blocker, flunarizine, which is unavailable in the United States, trials of medications in the prophylactic management of migraine in children are inconclusive. These include anticonvulsants, antidepressants, antihistamines, and antihypertensive agents.

Medication-overuse headache. The overuse of analgesic medications is stressed as a factor in the development of rebound and chronic daily headaches (CDH), and the withdrawal of all headache medications is recommended in their management (Ped Neur Briefs July 2005; 19:56) [3]. Used in moderation, non-steroidal anti-inflammatory analgesics are relatively safe and effective; when taken 15 days or more per month for 3 months or longer, they are likely to induce “medication overuse headache (MOH)” [4]. In Norway, the prevalence of CDH in the general population is 2 - 4%, and MOH accounts for one third of these cases; and 10% of the population is reported to take analgesics on a daily basis [5]. MOH is not only a problem of adults; it also occurs in children, even as young as 6 years [6]. MOH can result from overuse of any of the anti-migraine medications, including analgesics, triptans, ergots and medications containing barbiturates, tranquilizers, codeine and caffeine. A more general understanding of the risks of analgesic overuse should lead to a greater reliance on the recognition and avoidance of migraine triggers [7], and the support of controlled studies of prophylactic medications in childhood migraineurs.

A comparative multicenter study in adults treated at the onset of acute migraine found that a combination of acetaminophen, aspirin, and caffeine was significantly more effective than oral sumatriptan [8]. A further multicenter prospective study in adults found that a combination of naproxen sodium and sumatriptan in treatment of acute migraine was superior to therapy with either agent alone [9].