Pediatric Migraine: Recognition and Treatment

Home , Prevention of migraines

This prevalence ranks headache and migraine in the top five health problems of childhood. Despite its prevalence, migraine Pediatric Migraine: remains commonly undiagnosed or mis- Recognition and Treatment diagnosed, just as in adults in whom migraine is often attributed to sinus dis- 5 Andrew D. Hershey, MD, PhD ease. This misdiagnosis has been Paul K. Winner, DO demonstrated in adults to result in a significant impact on treatment, disability, and quality of life. Similarly in children, frequent headaches can cause a significant impact on disability,6,7 as well as quality of life,8,9 prompting the need for early recognition and treatment. The long-term outcome of child- The diagnosis of migraine headache in childhood rests on criteria similar to those hood headaches and evolution into used in migraine in adults. It is important, however, to appreciate several fun- adult headaches remains largely damental differences. These differences include the duration of attack, which unknown. It has been suggested that is often far shorter than in an adult, and the location of the attack, which may for adults migraine may represent a pro- be bilateral in many children. gressive disorder.10 In children, how- The treatment of children and adolescents with migraines includes treatment ever, the progressive nature is unclear modalities for acute attacks, preventive medications when the attacks are frequent, and further studies into longitudinal and biobehavioral modes of therapy to address long-term management of the outcome and phenotypic changes in disorder. The controlled clinical trials of medications in pediatric migraine have childhood headaches have yet to be suffered from high placebo response rates that may be related to the sites con- identified. ducting the study (ie, headache specialist vs clinical research organizations). The medications have proved to be safe in the pediatric age group. Diagnosis Treatment modalities for acute migraine include over-the-counter non- Historically, the diagnosis of headaches steroidal anti-inflammatory drugs (NSAIDs), as well as the oral triptans such and migraine in children has been based as sumatriptan succinate, rizatriptan benzoate, and zolmitriptan and the nasal on anecdotal experience, with only lim- spray formulations of sumatriptan and zolmitriptan. Subcutaneous suma- ited criteria. In 1988, the International triptan and parenteral dihydroergotamine have also been used limitedly. Headache Society adopted the Interna- Preventive treatment for patients with frequent or disabling migraines (or tional Classification of Headache Disor- both) includes the antidepressants amitriptyline hydrochloride and nortripty- ders.11 This classification allowed for dif- line hydrochloride, the anticonvulsants divalproex sodium and topiramate, and ferences in childhood headaches, notably the antihistaminic agent cyprohepatine hydrochloride. Biobehavioral approaches a shorter duration. However, this classi- aimed at addressing the fundamental lifestyle issues and nonpharmacologic fication was criticized by many investi- approaches to management are fundamental to long-term success. gators as not sensitive or specific enough for childhood headache disorders, and revisions were suggested.12 In 2004, the second edition of the From the Division of Neurology at the Cincinnati eadache, and more particularly International Classification of Headache Children’s Hospital Medical Center, University of migraine, is a frequent health Disorders (ICHD-2)13 was released. These Cincinnati College of Medicine, Cincinnati, Ohio (Dr H 1 Hershey); and Palm Beach Headache Center, Nova problem in children and adolescents. criteria provided improved recognition of Southeastern University, West Palm Beach, Fla (Dr Estimates are that headaches occur in childhood headaches in the footnotes for Winner). migraines. Among the improvements in Dr Hershey currently receives grants or con- up to 75% of adolescents and 25% of 2 tracts or honoraria from MedPointe, Inc; Ortho- younger children. The greatest impact criteria that were recognized was an McNeil Pharmaceutical, Inc; Johnson & Johnson; on a child and parent is from migraine, expanded duration of attacks from Pfizer Inc; GlaxoSmithKline; and Merck & Co, Inc. Dr between 1 and 72 hours, but still pos- Winner is a consultant, speaker, and researcher which occurs in up to 10.6% of children 3 with GlaxoSmithKline; Ortho-McNeil Pharmaceu- between the ages of 5 and 15 years, and sessing the features of a throbbing or pul- tical, Inc; AstraZeneca; Pfizer Inc; Merck & Co, Inc; 28% in children aged 15 to 19 years.4 satile headache of moderate to severe and Allergan; and he is a research advisor to Capnia. Address correspondence to Andrew D. Her- shey, MD, PhD, Associate Professor of Pediatrics and Neurology, Division of Neurology, MLC #2015, This continuing medical education publication supported by 3333 Burnet Ave, Cincinnati, OH 45229-3039. an unrestricted educational grant from Merck & Co, Inc E-mail: [email protected]

S2 • JAOA • Supplement 2 • Vol 105 • No 4 • April 2005 Hershey and Winner • Pediatric Migraine PATIENT WITH HEADACHE

Consider and Evaluate: Headache history Characterization of headache Conduct Comprehensive Disability Headache Examination Quality of life Family history

Abnormal?

Order Magnetic Resonance Imaging

Primary headache disorder? Secondary headache disorder? Yes Yes

Treatment for Preventive Biobehavioral Diagnose underlying cause acute episode treatment treatment and treat patient for it

Headache resolved? Primary Rescue If no, consider primary headache therapy therapy

Figure. Comprehensive approach to diag- could be adopted. These changes the headache components, as well as nosis and management of childhood included eliminating the lower limit for location on the head, impact of disability, headaches. duration based on the observation that and associated symptoms. Guidelines in children frequently have short-duration this evaluation and the use of ancillary migraines. We also found that simpli- tests have been developed.14 intensity with exacerbation with phys- fying the location to a focal location Headache disability can be assessed ical activity. Children with migraine pain versus a diffuse location increased the with the current PedMIDAS (Pediatric could have bifrontal or bitemporal pain, identification of childhood migraines. Migraine Disability Assessment Score),6 a though exclusively occipital pain requires These modifications remained incom- pediatric version of the adult disability further investigation. Migraine-associ- plete for recognizing all childhood instrument MIDAS.15 Quality of life also ated symptoms continued to require migraines, requiring some degree of clin- can be assessed with PedsQL (Pediatric nausea or vomiting (or both), or light ical recognition that they may still be Quality of Life), which has been validated and sound sensitivity. Additionally, the migraines. in pediatric migraine populations.8 Dis- criteria allowed for parental inference of ability and quality of life are important to these associated symptoms. Evaluation recognize, because they may be among These criteria have yet to be vali- The evaluation of childhood headaches the first signs of worsening migraines. dated and tested for children. We requires a complete general health assess- They may also be the first signs of recently investigated the sensitivity of ment, as well as a neurologic and response to therapy and can assist the the ICHD-2 criteria in a large group of headache history (Figure). Headache his- phyisician in recognizing this impact of pediatric migraine sufferers and found tory includes an identification of the fre- migraine, as well as validate for patients that further revisions or modifications quency, duration, severity, and quality of their improved response to treatment.

Hershey and Winner • Pediatric Migraine JAOA • Supplement 2 • Vol 105 • No 4 • April 2005 • S3 Evaluation should comprise a com- recommendation is not to use analgesics and several oral triptans have been prehensive headache examination,16 more than two to three times a week. studied in children.23 Sumatriptan suc- including recognition of muscular tight- Studies have shown the benefit of cinate has been studied in a double-blind, ness, cranial bruits, the Mueller sign to ibuprofen at a daily dose of 7.5 mil- placebo-controlled study with 25-mg, 50- assess for sinus tenderness, and a detailed ligrams per kilogram of body weight mg, and 100-mg tablets.24 Overall, the ophthalmologic evaluation with obser- (mg/kg) to 10 mg/kg for the treatment active treatment showed that 74% had vation of the optic disk. If results of the of acute childhood headaches.20,21 Both pain relief at 4 hours. The study’s pri- evaluation suggest the presence of a sec- ibuprofen and naproxen sodium have mary endpoint, however, was at 2 hours, ondary headache, further investigation been approved for children older than and statistical significance was not including laboratory evaluation or neu- 2 years. reached because of a high placebo roimaging may be necessary. Aspirin-containing compounds are response rate. of concern in children younger than 15 Headache recurrence rates are lower Treatment years owing to the historical concern of in children than adults and average Guidelines for the treatment of pediatric Reye’s syndrome. Although a combina- between 18% and 28% for sumatriptan. patients with headache have been tion of aspirin, caffeine, and acetami- Serious adverse events are rare in chil- recently adopted.17 These guidelines nophen has been shown effective in adult dren. Use of a 50-mg dose of sumatriptan review the most recent evidence for the acute migraine, it has not been tested in succinate compared with placebo had a treatment of childhood migraine and children for mild to moderate migraines. slightly increased risk of side effect for reveal that there is still much to be dis- sensations such as warmth and tight- covered. Triptans ness, burning pain, numbness, and

The recent identification that the The 5-hydroxytryptamine 1 (5-HT1) ago- strange feelings. Such side effects occurrence of allodynia during a nists (triptans) have revolutionized the occurred in 1% to 4% of children at this migraine in adults correlates with treatment of adults with moderate to dose and increased slightly at 100-mg response to treatment of acute migraine, severe migraines. Seven triptans are cur- doses. as well as with the progressive nature of rently available for use in the United Sumatriptan succinate nasal spray migraine, has emphasized the impor- States. Currently, there are no triptans at 5-mg, 10-mg, and 20-mg doses has tance of early recognition of headache approved by the US Food and Drug been studied in a randomized, double- and appropriate treatment.18,19 Whether Administration (FDA) for the use in pedi- blind, placebo-controlled trial in adoles- allodynia occurs in children is beginning atric migraine. They continue to be used cents aged 12 to 17 years, for a single to be elucidated. It is clear that some chil- in this age group, though additional attack.25 The 2-hour pain-free response dren describe symptoms consistent with studies need to be done in this age group showed the 20-mg dose was statistically allodynia, but the presence of allodynia to validate their effectiveness. significant with a 46% response rate com- has not been validated with quantitative Triptans are now available as injec- pared with 25% for placebo. The 20-mg sensory testing. In clinical practice, the tions (sumatriptan), nasal sprays (suma- dose of sumatriptan succinate also pro- occurrence of allodynic symptoms such triptan and zolmitriptan), tablets (suma- duced significant reduction in the as discomfort with wearing a ponytail, triptan, zolmitriptan, rizatriptan, migraine-associated symptom of photo- wearing a hat, backpack, glasses, or con- almotriptan malate, eletriptan hydro- phobia by 2 hours and yielded a reduced tact lenses may be an early identifier of bromide, naratriptan hydrochloride, and headache pain recurrence rate compared the presence of allodynia and the impor- frovatriptan succinate), and dissolving with placebo overall. There was no dif- tance of emphasizing the need of early tablets (zolmitriptan and rizatriptan). The ference, however, in the need for rescue treatment. wide variety of medications and formu- medication use in the active and placebo lations allows for flexibility in treatment groups. Treatment of Acute Migraine plans. A more recent nasal sumatriptan Over-the-Counter Medications Several of these formulations have succinate study using 5-mg, 20-mg, and Children and adolescents often respond been evaluated in children. One of the placebo dosing in a 1:1 ratio with 738 to over-the-counter medication, including initial studies evaluated subcutaneous adolescents did demonstrate that at 30 nonsteroidal anti-inflammatory drugs sumatriptan succinate at a dose of minutes, a 20-mg dose had a greater (NSAIDs) or combination analgesics. It is 0.06 mg/kg. It had an overall effective- headache relief (42% vs 33%, P .026).26 important to provide early treatment ness of 72% at 30 minutes and 78% at At 1 hour, this increased to 61% for active with children recognizing the onset of 2 hours, with a low recurrence rate of medicine versus 52% for placebo (not their headaches, as well as appropriate 6%.22 Children, however, often reject the significant). By 2 hours, response was dose based on weight, with the avoid- idea of needles or injections during increased to 68% for sumatriptan versus ance of overuse. By definition, overuse of headache attacks, and the use of the sub- placebo (P .025).26 Also, the increased simple analgesics for headache is defined cutaneous form of sumatriptan has been pain-free response was sustained. The as more than 15 headache treatment days limited in children. most common side effect was taste dis- per month of analgesic use.13 To lower As in adults, children prefer the oral turbance for the sumatriptan-treated risk of overuse of analgesics, the typical route of administration of medications, group. In summary, these studies

S4 • JAOA • Supplement 2 • Vol 105 • No 4 • April 2005 Hershey and Winner • Pediatric Migraine demonstrate that the 20-mg sumatriptan stratifies headaches and the subsequent measured using a simple scoring system succinate nasal spray provided rapid, treatment. This second method, how- such as PedMIDAS. Preventive medica- well-tolerated treatment across the ado- ever, often is not successful in children, as tions frequently used in children include lescent population. The results were sim- they have difficulty recognizing the the tricyclic antidepressants, antiepileptic ilar to those in studies of sumatriptan headache severity at its onset. medications, and antiserotonergic agents. nasal spray in adults. Although some of these medicines have Rizatriptan benzoate 5-mg tablets Ergot Alkaloids been tested in children, none is currently have also been evaluated in the 12-to-17- The ergot alkaloid compounds were first approved by the FDA for the use in the year age group in a double-blind, recognized nearly 100 years ago for their prevention of childhood headaches. placebo-controlled, parallel-group, single- usefulness in migraines. Dihydroergo- attack study.27 Of 149 adolescents using tamine (DHE-45) was originally devel- Tricyclic Antidepressants rizatriptan compared with 147 using oped for migraine in 194530; it fell out of Amitriptyline is the most widely used placebo, the response rate at 2 hours for favor until Raskin31 reported its effec- tricyclic antidepressant (TCA) for the rizatriptan-treated group was 66% tiveness in 1986. Subsequently, it is used headache prevention. Amitriptyline has compared with 57% for placebo. The frequently in inpatients, as well as emer- been used for many decades for its pain-free rate at 2 hours was 32% for the gency management of adult headaches. antidepressive properties and was first rizatriptan-treated group compared with Limited reports have shown the useful- recognized in the 1970s as an effective 28% in the group receiving placebo. No ness of intravenous (IV) DHE in an inpa- migraine therapy.36-38 Most of the studies serious adverse effects were noted. The tient setting to break status migrainosus using amitriptyline in children have been most common adverse effects reported or prolonged migraines in children.32 open-label studies; no placebo-controlled were fatigue, dizziness, somnolence, dry studies have been done. mouth, and nausea. In summary, Riza- Dopamine Antagonist In a crossover study comparing triptan benzoate, 5 mg, was well toler- Beginning in the 1970s, dopamine antag- amitriptyline with propranolol and ated, though because of the high placebo onists including prochlorperazine cyproheptadine, Levinstein39 found rate, statistical significance was not maleate and metoclopramide hydrochlo- amitriptyline to be effective in 50% to achieved. ride were used for the nausea and vom- 60% of the children. In an open-label Using both the 2.5-mg and the 5-mg iting effects of migraine headaches. At study, Hershey et al40 demonstrated that dose, another study examined oral that time, they were demonstrated to be amitriptyline hydrochloride at a dose of zolmitriptan in adolescents aged effective in minimizing the nausea and 1 mg/kg/d resulted in a perceived 12 to 17 years.28 The response rates were vomiting effects, as well as the effects of improvement in more than 80% of the 88% and 70%, respectively, with the treat- the migraine.33 Subsequently, others have children, with a subsequently decreased ment being well tolerated. Currently, studied the dopaminergic component of headache frequency and impact on the other studies are ongoing looking at nasal migraine development, and these com- children.40 Because of side effects such spray zolmitriptan and some of the pounds have been reanalyzed for their as somnolence, amitriptyline must be newer triptans, as well as uses of trip- usefulness in therapy for acute attacks.34 slowly titrated to this dose over 8 to 10 tans in even younger populations. In addition, studies demonstrate that for weeks, increasing the dose by 0.25 Several treatment models for acute effectiveness, the IV formulation is supe- mg/kg/d every 2 weeks. migraine have been applied to adults.29 rior to all of the formulations, with the The side effects of amitriptyline Ideally, it would be possible to translate oral route being ineffective or of limited include dry mouth, dry eyes, lighthead- these to the pediatric population. One is effectiveness. The current use, however, edness, constipation, sleepiness, and as rescue therapy or “stepwise treatment needs to be cautious because of the devel- unmasking of an underlying cardiac within an attack,” whereby the child opment of extrapyramidal side effects. arrhythmia. In general, however, most starts with an NSAID at an appropriate An open-labeled study in 20 children children tend to tolerate this TCA well dose of 10 mg of ibuprofen per kilogram demonstrated the effectiveness of without notable side effects. Nortriptyline of body weight at the onset of headaches. prochlorperazine in the emergency hydrochloride has often been used in If the child recognizes that this therapy is department setting, with rehydrating place of amitriptyline to reduce concern not effective, then a triptan is used as fluids.35 These agents can often be used about the sleepiness side effect; however, rescue therapy. to break an acute episode of status it does increase the concern of The alternative method is the “strat- migrainosus. arrhythmia. Therefore, regular moni- ified care model.” This model has been toring with electrocardiograms may be shown to be superior for management Preventive Therapy required if nortriptyline is chosen. of adult headache. It requires the patient Frequent headaches in children and ado- Serotonin selective reuptake to recognize the headache severity at the lescents often require preventive therapy. inhibitors (SSRIs) have been studied in onset. For either a mild or moderate Indications for the use of preventive the treatment of adults for headaches, headache, the patient takes the NSAID, therapy are having more than three to but they have not been studied in chil- whereas for severe headaches, the patient four headaches a month or significant dren. They are not as effective, however, takes the triptan. In this way, the patient disability due to headaches that can be as the TCAs, most likely because of non-

Hershey and Winner • Pediatric Migraine JAOA • Supplement 2 • Vol 105 • No 4 • April 2005 • S5 selective effects of the TCAs, compared both groups: 6.5% in the topiramate- be extrapolated. One study using nimo- with the SSRIs, suggesting that a more treated group and 4.1% in the group dipine in a double-blind, placebo-con- global decrease in neurotransmitter reup- receiving placebo dropping out of the trolled, crossover study in children take inhibition is needed to manage the study because of adverse events. Further showed no significant difference between hypersensitivity of childhood headache double-blind and placebo-controlled the group receiving the active drug and disorders. studies in both children and adolescents the group receiving placebo.54 have been completed or are under way. Anticonvulsant Therapy Nonsteroidal Anti-inflammatory In adults, anticonvulsant therapy is Antiserotonergic Agents Medications increasingly the mainstay for headache Cyproheptadine, an antihistamine with NSAIDs such as naproxen sodium and prevention. Recently, two antiepileptic antiserotonergic effects has long been ibuprofen have been suggested to be medications have been approved for the used for the prevention of childhood useful for the prevention of childhood prevention of migraine headaches in headaches.48 In addition, it may also have headaches. Recent evidence of medica- adults (divalproex sodium and topira- some calcium channel-blocking proper- tion overuse, however, limits their use- mate). Large-scale studies have demon- ties.49 Historic studies in small groups of fulness as preventive agents. strated both of these effective in children have shown the effectiveness of adults.41,42 In children, small group cyproheptadine given in a dosage range Preventive Treatment Strategy studies have shown the effectiveness of of 0.2 mg/kg/d to 0.4 mg/kg/d. It tends Currently, the FDA has not approved these agents. to be well tolerated, with the most sig- any medication for the prevention of For divalproex sodium, Caruso et nificant side effect being increased weight migraine in children. The FDA has al43 reported that 31 children aged 7 to 16 gain. Because of limitations in dosing approved five medications for adults, years were responsive in the 15-mg/kg and the significance of the weight gain, with established guidelines for their use. to 45-mg/kg dosage range, with 76% of cyproheptadine tends to be limited to The National Headache Consortium patients having a greater than 50% reduc- the younger children, with less useful- Guidelines identified several key points tion in headache frequency, while 18% ness in teenagers. for preventive medication management.55 had a greater than 75% reduction, and 6% These include proper education in the were headache-free. A study using stan- -Blockers use of preventive medications, with rea- dardized doses of either 500 mg or -Blockers have long been used for pre- sonable goals set. A typical goal of one to 1000 mg of sodium divalproate in 9- to vention of childhood headaches.50,51 two headaches per month or fewer is 17-year-olds also reported a reduction in Although one of the original studies recommended for a sustained period of severity on the Visual Analog Scale from demonstrated effectiveness, follow-up 4 to 6 months. The doses also must be 6.8 to 0.7, with a decrease in headache fre- studies have been controversial. In the titrated up slowly to minimize side quency from 6 per month to 0.7 per recent practice parameter,17 propranolol effects, and once an effective dose is month.44 Because of divalproex’s potential hydrochloride was found to have a reached, relief must be sustained for effects on bone marrow, liver, and pan- mixed responsiveness when used for 2 to 3 months before considering alter- creas, routine serum evaluation is needed. childhood headaches. Furthermore, in native medication. Physicians should Topiramate has recently been children, the drop in blood pressure due thoroughly discuss this long-term treat- approved for the prevention of migraines to -blockers, as well as exercise-induced ment plan with the parents and children, in adults.45 In a large-scale open-label asthma and depressive side effects, often so that they understand that the effort study, Hershey et al46 demonstrated its limits their usefulness in children. will be a long-term one and response effectiveness over placebo. In another will not be rapid. Once sustained relief is recent randomized, double-blind, Calcium Channel Blockers obtained, a plan to wean children off the placebo-controlled study, Winner et al47 Calcium channel blockers have been medication is also necessary. reported the effectiveness of topiramate extensively studied in adults for in children and adolescents. In their study headache prevention. Two groups52,53 Nonpharmaceutical Medication using a dose of 2 mg/kg/d to 3 mg/kg/d demonstrated the effectiveness of flu- Treatment (maximum dose 200 mg), in 162 children narizine, a calcium channel blocker avail- Herbal Remedies—Several herbal ranging in age from 6 to 15 years, topi- able in Europe, as a migraine-preventive remedies, as well as vitamins and related ramate resulted in a reduced mean agent. In a double-blind, placebo-con- compounds, have been suggested for use monthly migraine frequency from 5.4 trolled, crossover study in children, the for headaches in adults. Such remedies days per month to 1.9 days per month. baseline headache frequency was include Feverfew,56 riboflavin,57 and coen- Although not statistically significant, the reduced in those treated with flunarizine zyme Q10.58 None of these alternative results did trend toward significance (P compared with those receiving placebo.52 medicines has been adequately studied .065). A strong placebo response rate Flunarizine, however, is not currently in children for the prevention of again contributed to the lack of statis- available in the United States, and the headaches. Further studies are necessary tical significance. The rate of discontinu- use of other calcium channel blockers to quantify the effectiveness of any of these ation due to side effects was small in may not be as effective and results cannot compounds in childhood headaches.

S6 • JAOA • Supplement 2 • Vol 105 • No 4 • April 2005 Hershey and Winner • Pediatric Migraine Biobehavioral Treatment 4. Split W, Neuman W. Epidemiology of migraine spinal and supraspinal nociceptive neurons in among students from randomly selected secondary migraine. Brain. 2000;123:1703-1709. Increasing recognition of treatment of schools in Lodz. Headache. 1999;39:494-501. chronic disorders, the importance of non- 19. Burstein R, Collins B, Jakubowski M. Defeating medicinal treatment is necessary. This 5. Cady RK, Schreiber CP. Sinus headache or migraine pain with triptans: a race against the migraine? Considerations in making a differential development of cutaneous allodynia. Ann Neurol. has been classified as biobehavioral med- diagnosis. Neurology. 2002;58(9 Suppl 6):S10-S14. 2004;55:19-26. ication and includes such categories as 6. Hershey AD, Powers SW, Vockell ALB, LeCates SL, 20. Hämäläinen ML, Hoppu K, Valkeila E, San- promoting adherence, education of the Kabbouche MA, Maynard MK. PedMIDAS: Devel- tavuori P. Ibuprofen or acetaminophen for the patient, as well as maintaining healthy opment of a questionnaire to assess disability of acute treatment of migraine in children. Neurology. lifestyle habits.59-61 These healthy lifestyle migraines in children. Neurology. 2001;57:2034- 1997;48:103-107. 2039. habits include maintenance of adequate 21. Lewis DW, Kellstein D, Dahl G, Burke B, Frank fluid hydration, regular exercise pro- 7. Hershey AD, Powers SW, Vockell AL, LeCates LM, Toor S, et al. Children’s ibuprofen suspension grams, not skipping meals, eating a bal- SL, Segers A, Kabbouche MA. Development of a for the acute treatment of pediatric migraine. patient-based grading scale for PedMIDAS. Cepha- Headache. 2002;42:780-786. anced healthy diet, and maintaining ade- lalgia. 2004;24:844-849. quate sleep. Abstract reports have 22. Linder SL. Subcutaneous sumatriptan in the demonstrated that skipping meals and 8. Powers SW, Patton SR, Hommel KA, Hershey clinical setting: the first fifty consecutive patients AD. Quality of life in childhood migraines: clinical with acute migraine in a pediatric neurology office sleep alterations are both contributors to impact and comparison to other chronic illnesses. practice. Headache. 1995;35:291-292. frequent headaches in adults and chil- Pediatrics. 2003;112:e1-e5. 23. Hämäläinen ML, Hoppu K, Santavuori P. Suma- dren, and maintenance of healthy lifestyle 9. Powers SW, Patton SR, Hommel KA, Hershey triptan for migraine attacks in children: A ran- habits may help overall improve the out- AD. Quality of life in paediatric migraine: charac- domized placebo-controlled study. Neurology. come of childhood headache disorders. terization of age-related effects using PedsQL 4.0. 1997;48:1100-1103. Cephalalgia. 2004;24:120-127. Biobehavioral guidelines are under 24. 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Cephalalgia. 1988;8(Suppl Pediatrics. 2000;106:989-997. with a significant impact on the quality of 7):1-96. 26. Winner P, Rothner AD, Wooen J, Webster B, life of both children and parents. Proper 12. Winner P, Martinez W, Mate L, Bello L. Classi- Ames M. Randomized, double-blind, placebo-con- diagnosis and recognition are essential fication of pediatric migraine: proposed revisions trolled study of sumatriptan nasal spray in adoles- for management of these disorders. to the IHS criteria. Headache. 1995;35:407-410. cent migraineurs. Neurology. 2004;62:A182. Abstract. Migraine tends to be the most frequent 13. Headache Classification Subcommittee of the disorder seen in primary care offices and International Headache Society. The International 27. Winner P, Lewis D, Visser WH, Jiang K, Ahrens Classification of Headache Disorders. Cephalalgia. S, Evans JK. Rizatriptan 5 mg for the acute treat- tertiary referrals. 2004;24(Suppl 1):9-160. ment of migraine in adolescents: a randomized, Treatment and management require double-blind, placebo-controlled study. Headache. a three-leveled approach, including med- 14. Lewis DW, Ashwal S, Dahl G, Dorbad D, Hirtz 2002;42:49-55. D, Prensky A, et al. Practice parameter: evaluation ication management of acute episodes, of children and adolescents with recurrent 28. Linder SL, Dowson AJ. Zolmitriptan provides often requiring a primary and secondary headaches: report of the Quality Standards Sub- effective migraine relief in adolescents. Int J Clin medication; prophylactic treatment for committee of the American Academy of Neurology Pract. 2000;54:466-469. and the Practice Committee of the Child Neurology frequent or disabling headaches; and Society. Neurology. 2002;59:490-498. 29. Lipton RB, Stewart WF, Stone AM, Lainez MJ, biobehavioral management for lifelong Sawyer JP. 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