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

AgentDosePreparationCommon adverse effects
Antiepileptics
Topiramate1-10mg/kg/dayTablet 25,50,100Paraesthesia, somnolence, metabolic acidosis, cognitive dysfunction
Valproic acid15-30mg/kg/dayTablet ER: 200, 300, 500Liquid: 5ml/200mgSomnolence, termor, alopecia, weight gain, hyperammonemia, PCOS
Levetiracetam500-1500mg BDTablets 250, 500, 1000mgLiquid 100mg/mlSomnolence, fatigue, irritability, mood disturbances
Zonisamide100-600mg/dayTablets- 25,50, 100mgSomnolence, dizziness, anorexia,nausea, irritability
Gabapentin300-1200mg TDSTablet: 100,300,600Dizziness, sedation, ataxia, fatigue
Anti-histaminic
Cyproheptadine0.25-1.5mg/kg/dayTablet- 4mgLiquid suspension- 2mg/5mlDrowsiness, fatigue, increased appetite, weight gain
Anti-hypertensives
Propranolol2-4mg/kg/dayTablet-10,20,40Liquid suspension- 20,40/5mlFatigue, dizziness, constipation, hypotension, depression, exercise induced asthma
Flunarizine5-10mg HSTablet- 10 mgSedation, weight gain

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