Approach Considerations
The first step in treatment is to establish the diagnosis. When attacks have occurred on multiple occasions, with complete resolution between attacks, particularly in the presence of a positive family history of migraine, extensive laboratory evaluations and imaging can be avoided (see Workup). When the child is first seen acutely, particularly during the first episode, more extensive evaluation may be necessary to exclude alternative diagnoses.
Treatment of childhood migraine variants has 2 aspects, as follows:
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Short-term treatment of the specific attack
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Long-term medication to reduce the severity or frequency of episodes
Notably, no agents have adequate clinical trials to establish safety and efficacy for either relief or prevention of migraine in preadolescent patients. All treatment is based on weaker, often anecdotal, evidence. [21, 22]
If the clinical scenario suggests an underlying metabolic disease, mitochondrial cytopathy, or an inborn error of metabolism, consult a medical geneticist with expertise in metabolic disease.
Pharmacologic Therapy
Agents used for acute abortive treatment of childhood migraine variants include the following:
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Antiemetic or sedatives
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Minor analgesics
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Ergotamines
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Fluid replacement solutions, if vomiting is severe
Long-term prophylaxis is indicated if episodes are frequent or disruptive and if patients or families desire treatment and are ready to comply with daily medication. Agents used for this purpose include the following:
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Beta blockers
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Tricyclic antidepressants (TCAs)
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Aspirin (minidose)
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Anticonvulsants
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Cyproheptadine
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High-dose vitamin B-2 (riboflavin) combined with high doses of magnesium salts (usually magnesium oxide or citrate)
Hemiplegic migraine
For acute treatment of hemiplegic migraine, antiemetics, mild sedatives, and nonnarcotic pain relievers are generally safe. However, vasoconstrictors, triptans, and ergotamine preparations are contraindicated.
For long-term prophylaxis, any of the agents used to prevent typical migraines may also be used to prevent hemiplegic migraines. Beta blockers, low-dose TCAs, low-dose daily aspirin (stopped during febrile illnesses), low-dose anticonvulsants, and calcium channel blockers can be administered. For a few patients with specific channelopathies, acetazolamide (Diamox) can be used to prevent attacks.
Flunarizine, a calcium channel blocker that is not available in the United States, is probably the most effective agent for true alternating hemiplegia of childhood. Nonprescription alternative agents sometimes used for prevention include high-dose riboflavin, with or without magnesium supplementation and with or without herbs (eg, feverfew).
Cyclic vomiting of childhood
If mitochondrial cytopathy or organic aciduria is suggested or diagnosed, acute treatment of cyclic vomiting of childhood should be tailored to the underlying disorder. In general, early use of intravenous (IV) fluids containing adequate glucose (to prevent a catabolic state), parenteral or rectal antiemetics, and analgesics may abort the attack. Some patients respond to triptans or ergotamines.
For long-term treatment of cyclic vomiting of childhood, low-dose amitriptyline (or another tricyclic antidepressant) can be effective. Other antimigraine agents (eg, beta blockers, anticonvulsants, and calcium channel blockers) are occasionally useful. If the serum carnitine level is low, consider a trial of supplementation with L-carnitine. Some patients report improvement with mitochondrial cocktails containing high-dose B vitamins and coenzyme Q10. There is no firm evidence for these measures.
Further outpatient care
Encourage patients and families to keep headache diaries.
Diet and Activity
In migraine variants, as in all types of migraine, diet (particularly certain chemicals in food), may precipitate attacks in some patients. Accordingly, patients should keep a detailed diary of episodes, foods consumed, activities, illness, and medications. They should bring this diary to follow-up visits to assist in identification of precipitants and to facilitate assessment of the efficacy of treatment.
Rather than embarking on elimination diets, which are unlikely to be helpful, a trial of elimination may be useful if a particular food or additive is suspected of being a trigger for the attacks.
Some migraineurs experience attacks related to specific activities or exposures. The most common identifiable and avoidable precipitant is glare or flashing lights. Encourage children who are sensitive to glare to wear sunglasses when outdoors and to avoid strobes and strobelike conditions.
Medical Care
Referral to a child neurologist is indicated for children with migraines that fail to respond to abortive or first-line preventative medications. Additionally, a detailed eye exam including the optic nerve by ophthalmology is warranted, to ensure there is no evidence of elevated intracranial pressure that may warrant other treatments to preserve visual function.
