Effective Pediatric Migraine Relief May Depend on Intervention from Compounding Pharmacists
“We need to do a better job of ensuring we give kids with migraine the best medicines that will give them the best chance for success,” said Robert Nicholson, PhD, Director of Behavioral Medicine at Mercy Clinic Headache Center in St. Louis. You’d think children with migraines already receive the best, evidence-based treatments—but that’s often not the case. Dr. Nicholson was the lead author of a study that uncovered some worrisome news: opioids are often prescribed for kids with migraines. Compounding pharmacists are uniquely positioned to help parents find effective pediatric migraine relief before opioids are prescribed.
Pediatric Migraine Treatment Begins at the Pharmacy
Usually by the time children arrive in the emergency department with a migraine, they’ve been suffering for two to three days. During that time, parents try multiple medications, sometimes a prescription, but often a non-specific oral analgesic such as acetaminophen or ibuprofen. Whatever pharmaceutical they use, it fails, so they go to the ED. And this affects a lot of kids, with a worldwide prevalence of nine percent and rates in the United States of five percent.1 The age at which migraines appear is heartbreaking. The mean age of onset is 11 for girls and 7 for boys, but 20 percent develop migraines before they reach the age of five.
Here’s the takeaway for pharmacists: parents treat their children at home before they seek medical attention. They may not ask for your advice when they come in to buy meds, but if you take the time to reach out, you can intervene at this critical juncture. Your expertise is so valuable because the impact of migraine reaches beyond physical misery. Migraines affect learning and memory, hurt school performance and interfere with normal socialization long after the acute attack. And don’t forget that giving parents the information they need may prevent their child from taking unnecessary opioids.
Opioids Prescribed More Frequently than Approved Meds
Opioid dependency and deaths have reached epidemic proportions—an epidemic fueled by prescription drugs, and one in which compounding pharmacists can make a difference. The impact is well documented. Emergency departments around the country treat more than 1,000 people daily for misuse of prescription opioids and 2 million Americans have abused or become dependent on them.2 Based on a study presented at the American Headache Society’s annual conference in October 2015, children and adolescents with migraines may be at a higher risk for becoming one of the opioid statistics.
When data for 21,015 patients aged 6 to 17 and diagnosed with pediatric migraine or severe headache was reviewed, researchers found that nearly 16 percent were prescribed opioids as first-line treatment. By comparison, 9.7 percent of these patients were treated with triptans.3 We don’t have evidence to show cause-and-effect between opioids for pediatric migraine and future dependency or abuse, but the researchers expressed concerns about safety issues. They also believe that opioids may lead to migraine chronification and medication-overuse headaches.
Assessment for Pediatric Migraine
Given the complexity of migraines, it’s important to know the manifestations associated with different age groups. In younger children, migraines usually don’t have throbbing characteristics. About 10 to 20 percent experience aura, but rarely before 8 years of age. Even though migraines can last from 30 minutes to 48 hours, their duration is usually less than four hours. Age-specific symptoms include:4
- Infants: Parents may only see episodic head banging.
- Preschool: These children appear ill, have abdominal pain—expressed by crying, rocking or irritability—need to sleep and may seek darkness due to photosensitivity.
- Children ages 5 to 10: Bifrontal, bitemporal or retro-orbital headaches, associated with nausea, abdominal cramping and vomiting, are common. They often have sensitivity to light, noise and odors. Symptoms may also include swollen nasal passages, edema, excessive sweating, increased urination, diarrhea and thirst.
- Children over 10: Headache duration and intensity worsens. As kids get older, pulsating or throbbing is more likely to occur and the headaches shift to a unilateral, temporal location.
Treatment Options for Migraine
During an acute attack, sleep is the most effective treatment. When children can’t sleep due to pain, an ice pack placed on the affected artery may help. Acetaminophen or ibuprofen at a high but appropriate dose usually work when given in the early stages of the headache. There are two challenges with oral meds, however. Gastric stasis associated with migraine delays absorption and children with nausea or vomiting may resist taking meds. When this occurs, talk to parents—and reach out their pediatrician—to discuss compounding formulations that may be more palatable, such nasal sprays and a high-dose liquid.
The FDA has approved three triptans—sumatriptan, almotriptan and zolmitriptan—for acute migraine in adolescents, while rizatriptan is approved for children as young as six. Prophylactic drugs are only considered in patients with a history of four or more headaches monthly due to potential adverse effects. Potential side effects from medications must also be weighed against expected results, since only half of all patients experience a reduction of migraines of 50 percent or less. The list of prophylactic treatments includes:
- Selective serotonin reuptake inhibitors
- Anticonvulsants: gabapentin, valproate, divalproex, topiramate
- Tricyclic antidepressants: amitriptyline
- Beta blockers and cyproheptadine: Agents that block the 5-HT2 serotonin receptor are the most effective prophylactic agents in children.
Don’t hesitate to discuss non-pharmaceutical options. Physicians cover the basics, such as how to identify migraine triggers and the benefit of regular meals and bedtimes, but they may not recommend:
- Biofeedback and relaxation techniques: Patients who learn to relax can decrease the frequency and severity of migraine headaches. Biofeedback is one method that works well with many children and adolescents.
- Cognitive behavioral therapy: When CBT was combined with amitriptyline, children and adolescents with chronic migraines reduced the frequency of their headaches, reported researchers from the University of Cincinnati College of Medicine in a March 2016 study.5
Pharmacist Intervention Protects Young Patients
Whether you counsel parents before their child is diagnosed, during their efforts to manage chronic migraine, or you hit that period between home treatment and a trip to the ED, you have critical information they need. When you’re frustrated by lack of time and think you don’t have a few minutes to reach out, think about the effect of migraine on such young patients. Any guidance you provide improves every part of their life and don’t forget their parents, who become loyal customers and spread the word about the compassionate care they received at your pharmacy.
Pharmaceutica North America provides high-quality pharmaceuticals appropriate for treating pediatric migraines and we stay up-to-date with the latest research so we can help you determine the most effective treatments for young migraine patients. Please contact us today to discuss compounding options.
- “Acute Treatment Therapies for Pediatric Migraine: A Qualitative Systematic Review,” January 2016, http://www.medscape.com/viewarticle/858027_1 ↩
- “Prescription Opioid Overdose Data,” March 2016, http://www.cdc.gov/drugoverdose/data/overdose.html ↩
- “Study Shows High Rates of Opioid Prescribing in Pediatric Headache,” October 2015, http://www.painmedicinenews.com/Clinical-Pain-Medicine/Article/10-15/Study-Shows-High-Rates-of-Opioid-Prescribing-In-Pediatric-Headache/33856 ↩
- “Pediatric Migraine,” April 2016, http://emedicine.medscape.com/article/1179268-overview ↩
- “Cognitive Behavioral Therapy Plus Amitriptyline for Children and Adolescents with Chronic Migraine Reduces Headache Days to Less Than Four per Month,” March 2016, http://www.ncbi.nlm.nih.gov/pubmed/26992129 ↩