Department www.jpedhc.org Practice Guidelines

Section Editors Practice Guideline Polly F. Cromwell, MSN, RN, CPNP Bridgeport Health for Diagnosis and Department Bridgeport, Connecticut Robert J. Yetman, MD Management of University of Texas Medical School at Houston Migraine Headaches Houston, Texas in Children and Adolescents: Part Two

Kathy B. Gunner, MS, RN, CPNP, Holly D. Smith, MD, & Laura E. Ferguson, MD

This is the second part in a two- other loci), have led to improved part practice guideline for the di- understanding of the pathophysi- Kathy B. Gunner is Assistant Professor agnosis and management of head- ology of migraine (Borsook, Bur- of Pediatrics, University of Texas Health Science Center at Houston, Houston, aches (with emphasis on migraine stein, Moulton, & Becerra, 2006; Tex. headaches) in children and adoles- Pringsheim & Edmeads, 2004). In cents. Part One (Gunner & Smith,general, migraine may be under- Holly D. Smith is Assistant Professor of Pediatrics, University of Texas Health 2007) reviewed the epidemiology,stood as the complex interaction of Science Center at Houston, Houston, International Headache Society vasoconstriction and then vasodi- Tex. headache classification and diag- latation in response to neurotrans- Laura E. Ferguson is Associate nostic criteria, key points of the mitter release and subsequent ef- Professor of Pediatrics, University of history and physical examination, fects on ion channels (Dafer & Texas Health Science Center at and differential diagnoses of head- Birbeck, 2006). Occipital vasocon- Houston, and Medical Director of Well aches. Part Two focuses on the striction to a variety of reported Baby Nursery, Lyndon B. Johnson pathophysiology and management Hospital, Houston, Tex. “triggers” is thought to be the incit- of migraine headaches in children ing event; platelets aggregate with Correspondence: Kathy B. Gunner, MS, and adolescents. lymphocytes and leukocytes in an RN, CPNP, University of Texas Health Science Center at Houston, 6431 Fannin inflammatory “cascade,” resulting St, Houston, TX 77030; e-mail: PATHOPHYSIOLOGY in a release of and glu- [email protected]. Newer diagnostic and research tamate, which may increase pain J Pediatr Health Care. (2008). 22, 52-59. tools, such as magnetic resonance sensitivity of the arterial wall. This imaging, functional brain imaging response then causes irritation of 0891-5245/$34.00 with positron emission tomogra- the cranial nerves that lie in close Copyright © 2008 by the National Asso- phy scans, and localization of fa- proximity, especially to the tempo- ciation of Pediatric Nurse Practitioners. milial types of migraine to chromo- ral artery structures such as the doi:10.1016/j.pedhc.2007.10.009 somes 19p13 and 1q23 (among temporomandibular branch of the

52 Volume 22 • Number 1 Journal of Pediatric Health Care trigeminal nerve. In basilar artery BOX 1. Goals for Sleep: Children with migraines migraine and ophthalmoplegic mi- management of tend to have sleep disturbances graine, anatomic relationships may migraines ● A child should sleep 8 to 10 particularly predispose these areas hours nightly with scheduled of the brain to the described phe- 1. Reduce number and severity of bedtime and awakening. Some nomena in some patients. Once headaches adjustment can be made on vasoconstriction in an area of the 2. Reduce reliance on ineffective or weekends, but the regular bed- brain occurs, the sympathetic ner- undesired medications time should be resumed on Sun- vous system responds and com- 3. Improve quality of life day night (Powers & Andrasik, pensatory vasodilatation occurs in 4. Reduce reliance on acute head- 2005). neighboring areas of the menin- ache medications ● Adolescents can sleep later on geal circulation. This increase in 5. Educate and empower patients weekends as well but should and families to manage the blood flow is what is responsible plan to awaken briefly at the disease for the “throbbing” of the migraine 6. Reduce headache-associated regular time, get out of bed, headache. Conversely, the initial anxieties drink juice or eat a snack, and go vasoconstriction may be associ- back to sleep (Unger, 2006). Data from Silberstein, 2000. ated with depression of cortical ● A quiet routine before bedtime blood flow and decreased normal is recommended. Young chil- activity, resulting dren should avoid frightening in an aura. This initial vasocon- books, movies and television tions must be tried before the com- striction causes complex migraine shows. Night lights or white bination that provides optimal re- symptoms such as vision loss in noise might help. lief is found. These treatment op- ophthalmoplegic migraine, syn- Nutrition and dietary patterns tions are categorized into four cope in basilar artery migraine, ● The child should eat three meals main approaches: nonpharmaco- and hemiplegia in hemiplegic and one to two snacks a day at logic interventions, pharmacologic migraine. routine times. Breakfast should interventions, bio-behavioral mo- In the pubertal girl and in not be skipped. dalities, and complementary and women, a relative decrease in es- ● In general, avoidance diets are alternative interventions. Gener- trogen levels during menstruation not recommended for children ally, the interventions are initiated and premenstrual shifts in ion or adolescents unless a trigger in a stepwise fashion in the order channels are strong triggers for mi- has been identified. listed above. graine. Young women treated with ● About one third of children re- hormonal contraceptives usually port that certain foods trigger derive relief from migraine head- Management: headaches. Chocolate, citrus aches, but cerebral ischemia has Nonpharmacologic fruits, and are common been reported rarely as a pre- interventions triggers; processed meats, yo- sumed adverse effect of such ther- Nonpharmacologic options are gurt, fried foods, monosodium apy in those young women with effective in treating children/ado- glutamate, aspartame, and alco- both a family history of migraine lescents and are initiated before holic beverages are known trig- and cerebral ischemia (Ashkenazipharmacologic therapy is consid- gers as well (Lewis et al., 2005). & Silberstein, 2006). ered (Damen, Bruijn, Koes, et ● al., should be avoided be- 2006; Lewis, Yonker, Winner, &cause it is linked to sleep distur- Sowell, 2005; Unger, 2006). bances and mood disruptions, MANAGEMENT both headache triggers (Lewis et The management plan for mi- al., 2005). graine relief in children and ado- Maintenance of a headache ● Inadequate hydration should be lescents is based on goals (Box 1) calendar avoided. Adolescents are encour- established by the American Acad- ● Maintenance of a headache cal- aged to drink 2 liters (L) of non- emy of Neurology (Silberstein, endar can assist with trigger caffeinated liquids, ideally water, 2000) and several general princi-identification and allows for per day, increasing to3Laday ples (Box 2). The most significant management plan adjustment during the summer and periods of concept within this framework is based on an individual’s re- exertion (Powers & Andrasik, that the plan is individualized sponse to interventions. 2005). based on the symptoms, responses ● Adjustment of lifestyle habits Physical activity to treatment, and patient/family should include maintenance of ● Children and adolescences are preference for treatment options. routine patterns of sleeping, eat- encouraged to participate with Often a variety of treatment op- ing, and exercise. family or friends in at least 30

Journal of Pediatric Health Care January/February 2008 53 BOX 2. General principles of management of migraines in children and adolescents

1. Establish a diagnosis 2. Assess the degree of disability and impact on the child’s/adolescent’s quality of life; evaluate school attendance and school performance, especially in the areas of attention, math, and performance; consider a stress or depression-related etiology if child is often absent from school and the headaches affect other family members’ ability to work or participate in outside activities 3. Educate the child and family about the condition and risk/benefit ratios of treatment options 4. Establish realistic expectations ● Set appropriate goals ● Discuss the expected benefits of therapy and time course to achieve them ● Empower the patient and family to be involved in management (such as tracking progress with a headache diary or calendar) 5. Create an individualized, formal management plan ● Consider the patient’s response to and tolerance for specific medications ● Consider comorbidities and treatment options dictated by these conditions (for example, children with depression may benefit from as migraine prophylaxis, and those with asthma should not take ␤-blockers as migraine prophylaxis) ● Encourage recognition and avoidance of triggers

Data from Linder (2006), Rosenblum & Fisher (2001), and Silberstein (2000).

minutes of enjoyable, aerobic activity 3 to 7 days a week. Prioritization of activities and Adjustment of lifestyle habits should include evaluation of performance maintenance of routine patterns of sleeping, expectations ● Excessive or unrealistic expecta- eating, and exercise. tions of performance in school, athletics, and other activities may contribute to migraines. treatment, and improve the quality nonstatistically significant bene- Sport performance and college of life (Lewis et al., 2004). In fitsgen- in abortive relief (Lewis et al., acceptance are two common eral, prophylactic medications are 2004). stressors. If after-school activities considered when patients have ● Intravenous are excessive, consideration more than four headaches per (Compazine) works better than should be given to eliminating month or the headaches are so se- intravenous ketorolac (Damen some of the activities. vere that they interrupt normal ac- et al., 2005). Management: Pharmacologic tivities (Damen, Bruijn, Verhagen,Acute/abortive: 5- Interventions et al., 2006). To minimize adverseHydroxytryptamine Few well-designed trials have effects, prophylactic medications (5-HT1, ) evaluated the acute pharmacologic are started at the lowest dose and ● 5-Hydroxytryptamine receptor management of migraine in chil- titrated upward as needed (Unger, agonists promote cerebral vaso- dren (Damen et al., 2005; Lewis2006 ).et Unfortunately, because of constriction and block the neu- al., 2004). For this reason, ibupro-the lack of evidence, the FDA has ropeptide-mediated inflamma- fen and naproxen are the only not approved any preventive mi- tory response resulting from medications approved by the U.S. graine medications in children. Food and Drug Administration Given the available evidence, the trigeminal stimulation. ● (FDA) for the acute treatment of medications listed in Table 2 canNasal , studied in migraines in children from 2 to 18 be considered (Unger, 2006). children 12 years and older, ap- years of age (Lewis et al., 2005), pears to be safe and efficacious. although a variety of agents are Acute/abortive: Analgesics Subcutaneous sumatriptan is ef- commonly utilized (Table 1). ● Ibuprofen works better than pla- fective, but adverse effects such Migraine preventive medica- cebo (Damen et al., 2005; Lewisas chest pressure often are seen. tions, when given, should de- et al., 2004; Lewis et al., 2005Oral). triptans do not appear to be crease the number, intensity, and ● When compared with acetamin- more effective than placebo duration of headaches, improve ophen, ibuprofen offers no sta- (Damen et al., 2005; Lewis et al., how patients respond to acute tistically significant but some 2004; Lewis et al., 2005).

54 Volume 22 • Number 1 Journal of Pediatric Health Care TABLE 1. Medications for acute/abortive migraine therapy

Generic name Brand name Type of drug Amount per dose (maximum/dose)

Acetaminophen Tylenol Analgesic 15 mg/kg PO (1000 mg) Ibuprofen Advil/Motrin NSAID 10 mg/kg PO (800 mg) Naproxen Aleve NSAID 5-7 mg/kg PO (500 mg) *Ketorolac Toradol NSAID 0.5 mg/kg IM/IV (30 mg) *Sumatriptan Imitrex 25-100 mg PO 5-20 mg IN; 6 mg SQ * Maxalt Triptan 5-10 mg PO * Zomig Triptan 1.25-2.5 mg PO * Migranal Ergot 0.1 mg IV (6-9 y) 0.2 mg IV (9-12 y) 0.3 mg IV (12-16 y) *Prochlorperazine Compazine Antiemetic 0.1-0.15 mg/kg IM (10 mg) IM, Intramuscular; IN, intranasal; IV, intravenous; NSAID, nonsteroidal anti-inflammatory drug; PO, by mouth; SQ, subcutaneous. Data from Lewis, Yonker, Winner, & Sowell (2005); Robertson & Shilkofski (2005); Tarascon Pocket Pharmacopoeia, 2007; and Unger (2006). *Not approved by the U.S. Food and Drug Administration for use in children and adolescents with migraine headaches.

TABLE 2. Oral medications for prophylactic migraine therapy

Generic name Brand name Type of drug Amount per day (maximum per day)

* Inderal ␤-blocker 1-4 mg/kg/day bid-tid; 40 mg bid max adult dose to start (240 mg max adult dose) * Elavil Tricylclic 0.1-2 mg/kg/day q HS; 0.25 mg/kg/d max to start; need to titrate; Ͼ1 mg/kg/day give bid and monitor EKG (75 mg) *Valproic acid Depakote 15-30 mg/kg/day bid; 250 mg bid max to start in adult (1000 mg) * Topamax Anticonvulsant 2-3 mg/kg/day bid; 25 mg q HS max to start; need to titrate; Ͼ50 mg, give bid (200 mg) * Periactin 0.25-0.4 mg/kg/day bid-tid (2-6 yo, 12 mg) (7-14 yo, 16 mg) (adult, 32 mg) bid, Twice a day; EKG, electrocardiogram; HS, at bedtime; q, every; tid, three times a day; yo, year old. Data from Lewis, Yonker, Winner, & Sowell (2005); Robertson. & Shilkofski (2005);. Tarascon Pocket Pharmacopoeia (2007); & Unger, J. (2006). *Not approved by the U.S Food and Drug Administration for use in children and adolescents with migraine headaches.

● Although not FDA labeled for warmth, stinging sensation, or par- dihydroergotamine can result in use in persons younger than 18 esthesias) (Damen et al., 2005). nausea necessitating pretreat- years, triptans can be considered —Contraindications: cardiovas- ment with an oral anti-emetic for children 12 years and older cular disease; uncontrolled hyper- such as (Lewis et when there is no response to tension; hemiplegic or basilar mi- al., 2005). analgesics (Lewis et al., 2004;graines; use of 5-HT1 in Acute/abortive: Anti-emetics Lewis et al., 2005). the past 24 hours; and use of a ● Effective agents include pro- ● For some children, giving a dose monoamine oxidase inhibitor in chlorperazine (Compazine), par- and monitoring for reactions or the past 2 weeks (Lewis et ticularlyal., in those with nausea adverse effects in the office 2005). and vomiting, albeit with the (whether or not they have a mi- Acute/abortive: Ergot theoretic risk of extra-pyramidal graine) may be indicated (Un- (dihydroergotamine) adverse effects (Damen et al., ger, 2006). ● Ergot alkaloids are available in 2005; Lewis et al., 2005). ● Contraindications and adverse oral, intranasal, subcutaneous, Prophylaxis/Anti-hypertensives effects occur in adults. intramuscular, and intravenous ● channel blockers selec- —Adverse effects: bad taste routes. Oral dihydroergotamine tively inhibit vasoactive sub- from the nasal form; nausea; chest appears to be of no benefit stances(Da- on cerebrovascular discomfort; triptan sensation (i.e., men et al., 2005). Intravenoussmooth muscle. Nimodipine is

Journal of Pediatric Health Care January/February 2008 55 not consistently effective, but monitoring adolescents and years old before they can com- flunarizine (not available in the young adults initially started on prehend the concepts involved United States) was effective in antidepressants (U.S. FDA, 2007). in these techniques (Powers & several trials (Lewis et al., 2004;● The FDA issued an alert stating Andrasik, 2005). Lewis et al., 2005). that there is a possibility of a life- ● Biofeedback frequently is used ● ␤-Blockers (propranolol) have threatening serotonin syndrome as an adjunct to relaxation train- been studied in children and are (change in mental status, auto- ing. Two different techniques of questionable effectiveness nomic instability, neuromuscular can be used with children and (Lewis et al., 2004; Lewis et abnormalities,al., and gastrointestinal adolescents: 2005); other agents (timolol, symptoms) when patients are tak- — Electromyographic activity, atenolol, metoprolol, and nado- ing both triptans and SSRIs (U.S.in which an electrical dis- lol) have not been effective (Da-FDA, 2006). charge in the muscle fiber in- men, Bruijn, Verhagen, et Prophylaxis/anticonvulsantsal., dicates skeletal tension. 2006). ␤-Blockers cannot be ● Valproic acid (Depakote) was — Peripheral skin temperature used in patients with a history of effective in open-label trials in monitoring measures vaso- asthma and are used with cau- children and adolescents, but motor mechanisms. As the tion in patients with a history of the adverse effects in adolescent child relaxes, the skin tem- depression. women, including hair loss, perature rises. ● An ␣-adrenergic agonist () weight gain, and possible terato- was found to be no better than genic effects, must be consid- placebo in children (Lewis et eredal., (Lewis et al., 2004). Management: Complementary 2004). ● Newer antiepileptic medications and Alternative Interventions Prophylaxis/antidepressants (, levetiracetam, and Few studies in adults or chil- ● Amitriptyline (Elavil) reduces topiramate) reduced headache dren have evaluated the efficacy headache frequency and strength frequency in open-label, retro- and safety of various comple- but not duration (Lewis et spectiveal., trials (Lewis et al., 2004;mentary and alternative methods 2004; Lewis et al., 2005). Lewis et al., 2005). of migraine control. Herbs (fever- ● Selective serotonin reuptake in- Prophylaxis/ few, , and valerian root), hibitors (SSRIs) have not been ● Cyproheptadine has antisero- minerals (), and vita- studied in children or adoles- tonergic and calcium channel mins (riboflavin) commonly have cents for the prophylaxis of mi- blocker effects; it is used exten- been used in the treatment of mi- graines (Lewis et al., 2005), andsively for migraine prophylaxis graines (Lewis et al., 2005). Of the black box warning concern- in young children but has not these, only feverfew in one study ing increased suicidality, but not been well studied and has the in adults was found to be an ef- suicide, in adolescents may limit adverse effects of sedation and fective preventative medication their use (U.S. FDA, 2007). How-increased appetite (Lewis et (al.,Diener, Pfaffenrath, Schnitker, ever, in children with co-morbid 2004; Lewis et al., 2005). Griede, &Henneike-von Zepelin, anxiety and/or depression, SSRIs Management: Biobehavioral 2005). Evidence-basedtreatment may be the best option. Of the Modalities recommendations in children for SSRIs, only fluoxetine is ap- Relaxation training and biofeed- the use of hypnosis, acupuncture, proved in children and adoles- back programs are aimed at reduc- transcutaneous electrical nerve cents for major depressive disor- ing the frequency and severity of stimulation, chiropractic or osteo- ders (U.S. FDA, 2007). Themigraines. The combination of pathic cervical manipulation, oc- American Academy of Child and biofeedback and relaxation treat- clusal adjustment, and hyperbaric Adolescent Psychiatry published ments provides the child/adoles- oxygen as preventive or acute a Practice Parameter for Assess- cent with objective data to evalu- therapy for migraine are not yet ment and Treatment of Children ate their response (Powers possible& (Alecrim-Andrade, Ma- and Adolescents with Depres- Andrasik, 2005). While all childrenciel-Junior, Cladelleas, Correa-Filho, sive Disorders. It concluded that with migraines may benefit from & Machado, 2006; Silberstein, the risk to benefit ratio for SSRI these therapies, they are reserved 2000). Some persons have recom- use in pediatric depression ap- primarily for children with dis- mended that some of these treat- pears to be favorable with care- abling headaches. ment modalities may be consid- ful monitoring for suicidal ● Relaxation treatments include ered by the patient who is not thoughts and behavior as well as progressive muscle relaxation, interested in pharmacologic op- for other adverse effects (Birma-diaphragmatic or deep breath- tions or for patients who prove to her & Brent, 2007). Thfur-e FDA ing, and guided imagery. Gener- be refractory to conventional ther- ther defines specific criteria for ally, children must be at least 7 apies (Lewis et al., 2005).

56 Volume 22 • Number 1 Journal of Pediatric Health Care BOX 3. Resources

For child/family: American Academy of Neurology (AAN) 1080 Montreal Ave St. Paul, MN 55116 The AAN and the Child Neurology Society have developed a fact sheet entitled “AAN guideline summary for patients, parents and caregivers: Treatment of migraine headache in children and adolescents.” It is located at the following Web site: http://www.aan.com/professionals/practice/pdfs/Headaches_Peds_Patients.pdf American Council for Headache Education 19 Mantua Rd Mt. Royal, NJ 08061 Web site: http://www.achenet.org The Web site has a section, “Kids and Headaches,” that includes several handouts describing types of migraines, triggers, and other information useful for understanding and preventing migraines in children and adolescents. The Headache Care Center Web site: www.headachecare.com A comprehensive site with in-depth coverage of topics ranging from types and treatments of headaches to a page devoted to self-evaluation. “The Migraineur’s Guide to Migraine” is a helpful guide to understanding phases of migraines, detailing preventative lifestyle habits, and detailing concerns that are common to individuals with migraines. This site is geared toward adults but would be beneficial to older adolescents and young adults. Lewis, D. W. (2002 February 15). Migraine headache in children and adolescents. American Family Physician. This patient handout provides a comprehensive review of description of migraines, causes, treatments, and actions parents can take to prevent migraines. This handout follows the following article: Lewis, D. W. (2002, February 15). Headaches in children and adolescents.American Family Physician. Retrieved from www.aafp.org/afp//20020215/625.html National Institute of Neurological Disorders (NINDS), National Institute of Health. Web site www.ninds.nih.gov/disorders/headche/detail_headache.htm This Web site has several publications that address headaches. One publication, Headache: Hope Through Research, thoroughly discusses causes, diagnosis, and treatments of all types of headaches with special emphasis on migraine headaches. The Web site also lists other resources. For health care providers: Fetrow, C. W. & Avila, J. R. (1999). Complementary and alternative medicines. Springhouse, PA: Springhouse Corp. This book is written by two pharmacists, and each medicine has the following information: Common trade names, common forms, chemical components, actions, reported uses, dosage, adverse reactions, interactions, contraindications and precautions, special considerations, points of interest, analysis, and references. Primary Care Network 1230 E. Kingsley Springfield, MO 65804 Web site: www.primarycarenet.org This not-for-profit association of health care providers provides CME accredited education by offering free seminars, teleconferences, and online and interactive education. There are several programs on management of patients with migraines primarily for adult patients. This organization also conducts clinical trials and therapy research at several sites in the United States.

PATIENT AND FAMILY daily regardless of pain (Powersthe & medication should be included EDUCATION Andrasik, 2005). in the letter (Powers & Andrasik, The patient and family need to Fluids are taken with the abor- 2005). understand that the medicine pre- tive medication to ensure hydra- Older children should be taught scribed is to be taken as directed. If tion (Powers & Andrasik, 2005).the names, dosages, and usage of the patient is prescribed acute/ A medical authorization docu- all medications (Powers & An- abortive and prophylactic medica- ment signed by the clinician and drasik, 2005). tions, the difference between the guardian should be sent to the The patients are told that adher- two must be explained. Acute/ school explaining the need for im- ence to lifestyle changes may result abortive medications are taken at mediate administration of the in the prophylactic medications be- the first sign of the headache; pro- abortive medication accompanied ing discontinued after 6 to 12 phylactic medications are taken by fluids. The name and dosage of months (Powers & Andrasik, 2005).

Journal of Pediatric Health Care January/February 2008 57 The provider should emphasize is based on the comfort level of the Psychiatry: Practice parameter for the avoidance of other non-prescribed NP, the relationship with the su- assessment and treatment of children or non-recommended pain medi- pervising physician, and/or the ap- and adolescents with depressive disorders. Retrieved September 26, cations (i.e., over the counter). Us- propriate state nurse practice act. 2007, from www.aacap.org/galleries/ age of these medications can lead Practice Parameters/InPress_2007_ to “overuse” rebound headaches SUMMARY DepressiveDisorders.pdf (Lewis et al., 2005). The diagnosis of migraine head- Borsook, D., Burstein, R., Moulton, E., & Source for handouts for patient aches in children and adolescents Becerra, L. (2006). Functional imaging of the trigeminal system: Applications teaching and other information for is complex and based on guiding to migraine pathophysiology. Head- both families and health care pro- goals and general principles. In all ache: The Journal of Face and Pain, 46, fessionals are listed in Box 3. cases a thorough history and phys- S32-S38. ical examination encompasses the Dafer, R., & Birbeck, G. (2006). Migraine REFERRALS numerous and/or potentially life- variants. Retrieved July 24, 2007, from The treatment of migraine head- threatening differential diagnoses. http://www.emedicine.com/NEURO/ topic219.htm aches is multifactorial and may re- The individualized plan is based Damen, L., Bruijn, K. J., Verhagen, A. P, quire interventions beyond the on the patient’s symptoms, con- Berger, M. Y., Passchier, J., & Koes, scope of the nurse practitioner tributing factors, response to tried B. W. (2005). Symptomatic treatment (NP). Children with comorbid de- therapies, and patient and family of migraine in children: A systematic re- pressive disorders or other psychi- preference for treatment options. view of medication trials. Pediatrics, atric disorders who would benefit Additionally, a stepwise approach 116, 295-302. Damen, L., Bruijn, J., Koes, B. W, Berger, from psychotherapy and or phar- is critical when treating children, M. Y., Passchier, J., & Verhagen, A. P. macotherapy should be referred to primarily because few medications (2006). Prophylactic treatment of mi- a psychiatrist. Similarly, patients are approved by the FDA for use in graine in children. Part 1: A systematic review of non-pharmacological trials. Cephalalia, 26, 373-383. Damen, L., Bruijn, J., Verhagen, A. P., Berger, M. Y., Passchier, J., & Koes, B. W. (2006). Prophylactic treatment of If the patient is prescribed acute/abortive and migraines in children. Part 2: A system- atic review of pharmacological trials. prophylactic medications, the difference Cephalgia, 26, 497-504. between the two must be explained. Diener, H. C., Pfaffenrath, V., Schnitker, J., Griede, M., & Henneike-von Zepelin, H.-H. (2005). Efficacy and safety of 6.25 mg. t.i.d. feverfew CO2-extract (MIG-99) in migraine prevention—a ran- who would benefit from biobehav- children and young adolescents. domized, double-blind, multicentre, ioral therapies require a referral to Children and adolescents who re- placebo-controlled study. Cephalalgia, a psychologist skilled in these quire psychotherapy or biobehav- 25, 1031-1041. methods. ioral therapy or who are refractory Gunner, K. B., & Smith, H. D. (2007). Prac- Another group of children and to prescribed therapy should be tice guideline for the diagnosis and management of migraine headaches in referred to the appropriate special- adolescents who require referral children and adolescents: Part One. are those who are refractory to ist. The NP also must weigh the Journal of Pediatric Health Care, 21, prescribed therapy, especially risk and benefits of prescribing 327-332. those with chronic daily head- medications that are not FDA ap- Lewis, D., Ashwal, S., Hershey, A., Hirtz, aches or migraine variants. This proved and/or require close D., Yonker, M., & Silberstein, S. monitoring. (2004). Practice parameter: Pharma- group of patients should be re- cological treatment of migraine head- ferred to a pediatric neurologist or ache in children and adolescents. a pediatric headache clinic. REFERENCES Neurology, 63, 2215-2224. Lastly, the NP must recognize Alecrim-Andrade, J., Maciel-Junior, J. A., Lewis, D. L., Yonker, M., Winner, P., & Sow- that the majority of the medica- Cladelleas, X. C., Correa-Filho, H. R., & ell, M. (2005). The treatment of pediatric migraine. Pediatric Annals, 34, tions for acute and prophylactic Machado, H. C. (2006). Acupuncture in migraine prophylaxis; A randomized 449-460. treatment are non-FDA approved sham-controlled trial. Cephalalgia, 26, Linder, S. L. (2006, May). A practical ap- for use in children and young ad- 520-529. proach to pediatric headaches. Paper olescents, may not been have stud- Ashkenazi, A., & Silberstein, D. (2006). Hor- presented at the Pediatric Nursing Clin- ied for use in children and adoles- mone-related headache: Pathophysiol- ical and Professional Update “Care for ogy and treatment. CNS Drugs, 20, Kids” Conference, Greater Texas cents for prophylaxis of migraines, 125-141. Chapter National Association of Pediat- or carry a black box warning. The Birmaher, B., & Brent, D. (2007). American ric Nurse Practitioners and El Centro decision to use these medications Academy of Child and Adolescent College, Dallas, TX.

58 Volume 22 • Number 1 Journal of Pediatric Health Care Powers, S. W., & Andrasik, F. (2005). Biobe- Silberstein, S. D. (2000). Practice param- als. Selective serotonin reuptake inhib- havioral treatment, disability, and psy- eter: Evidence-based guidelines for itors (SSRIs), selective serotonin nor- chological effects of pediatric head- migraine headache an evidence- epinephrine retake inhibitors (SNRLs), ache. Pediatric Annals, 34, 461-465. based review: Report of the quality 5-Hydroxytrypamine receptor agonists Pringsheim, T., & Edmeads, J. (2004). Effective standards subcommittee of the (triptans). FDA Alert. Potentially treatment of migraines: Terminating acute American Academy of Neurology. life-threatening serotonin syndrome attacks, reducing their frequency. Post- Neurology, 55, 754-762. with combined use of SSRIs or SNRIs graduate Medicine, 115, 28-50. Tarascon Pocket Pharmacopoeia. (2007). and Triptan medications. Retrieved July Robertson, J., & Shilkofski, N. (2005). The Lompoc, CA.: Tarascon Publishing. 26, 2007, from www.fda.gov/cder/drug/ Harriet Lane handbook (17th ed., pp. Unger, J. (2006). Pediatric migraine: Clin- infosheets/HCP/triptansHCP.htm 698-1009). Philadelphia: Elsevier. ical pearls in diagnosis and therapy. U.S. Food and Drug Administration. (2007). Rosenblum, R. K., & Fisher, P. G. (2001). A Consultant for Pediatricians, 5, 545- use in children, adoles- guide to children with acute and 551. cents, and adults. Retrieved Septem- chronic headaches. Pediatric Health U.S. Food and Drug Administration. (2006). ber 26, 2007, from www.fda.gov/cder/ Care, 15, 229-235. Information for healthcare profession- drug/adtidepressants/default.htm

Journal of Pediatric Health Care January/February 2008 59