Preventive therapy for migraine in children

Indication to start preventive therapy

Preventive therapy should be restricted to those children whose experience

• Headache frequency atleast one headache/week or more than three headaches /month
• Prolonged and severe headaches, even if infrequent
• Headache in which abortive treatment fails, overused or is contraindicated by the child

The goals of treatment are to reduce headache frequency thereby reducing the progression to chronic daily headache and improve quality of life. It typically takes at least 8 to 12 weeks to cause a recognizable effect, hence switch over to other preventive drugs every few weeks is not advisable.

Choosing a drug for preventive therapy in Migraine

Choice depends on comorbid conditions associated with migraine. Following drugs are preferred in certain situations as following:

• Topiramate: preferred in obese child, avoided in child with renal stone (US FDA approved in children > 12 years)
• Valproate: Thin built child, child having epilepsy (US FDA approved in adults)
• Amitryptiline: Teenager with sleep problems
• Propranolol: Not good for asthmatic and competitive athlete
• Cyproheptadine: In younger children, syrup available, child with allergic disorder

How long a child should receive preventive therapy?

The target is to reduce headache frequency to three or less/ month sustained for 4-6 months after which the preventive therapy should be gradually weaned.

Preventive medications for Migraine

Agent	Dose	Preparation	Common adverse effects
Antiepileptics
Topiramate	1-10mg/kg/day	Tablet 25,50,100	Paraesthesia, somnolence, metabolic acidosis, cognitive dysfunction
Valproic acid	15-30mg/kg/day	Tablet ER: 200, 300, 500Liquid: 5ml/200mg	Somnolence, termor, alopecia, weight gain, hyperammonemia, PCOS
Levetiracetam	500-1500mg BD	Tablets 250, 500, 1000mgLiquid 100mg/ml	Somnolence, fatigue, irritability, mood disturbances
Zonisamide	100-600mg/day	Tablets- 25,50, 100mg	Somnolence, dizziness, anorexia,nausea, irritability
Gabapentin	300-1200mg TDS	Tablet: 100,300,600	Dizziness, sedation, ataxia, fatigue
Anti-histaminic
Cyproheptadine	0.25-1.5mg/kg/day	Tablet- 4mgLiquid suspension- 2mg/5ml	Drowsiness, fatigue, increased appetite, weight gain
Anti-hypertensives
Propranolol	2-4mg/kg/day	Tablet-10,20,40Liquid suspension- 20,40/5ml	Fatigue, dizziness, constipation, hypotension, depression, exercise induced asthma
Flunarizine	5-10mg HS	Tablet- 10 mg	Sedation, weight gain