Headache and migraine in children: SAQ

This girl has migraine without aura. She has had more than five attacks of bilateral, throbbing, frontotemporal headache lasting three to four hours, with a moderate-to-severe quality implied by her need to stop activity, accompanied by nausea, and with photophobia and phonophobia evident in her seeking a dark, quiet room. These features meet the ICHD-3 criteria, and the family history of migraine in her mother strengthens the diagnosis. Her normal blood pressure, fundoscopy, and neurological examination, and the absence of any red flag, confirm a primary headache and close the investigation loop. The two features that change the plan are her frequency (eight attacks, or more than four headache days a month, which crosses the prophylaxis threshold) and her analgesic use (combination paracetamol and codeine on five days of the last week, which is medication overuse and the most reversible reason her headaches are escalating). [1]

Question 1 (10 marks)

Outline your acute abortive management of this girl's attacks, and justify your investigation plan. [8]

My first step is to stop the codeine. Opioids and codeine have no place in routine paediatric migraine: they are ineffective, sedating, and carry a high risk of dependence and overuse, and her use of combination analgesia on five days a week is the principal driver of her escalating headaches. The acute plan is ibuprofen 10 mg per kg, given early in the attack while the pain is still building, as first-line treatment, with paracetamol 15 mg per kg as an alternative. The 2016 Cochrane review by Richer and colleagues found ibuprofen and paracetamol the best-supported acute agents, with a number needed to treat of about three for ibuprofen to achieve two-hour pain freedom. [8]

For the moderate-to-severe attack that does not respond to simple analgesia, I would add a triptan. Sumatriptan nasal spray at 10 to 20 mg, or rizatriptan as a dispersible tablet, are the triptans with the strongest paediatric evidence, and I would use one of these for an attack that is disabling or slow to respond. An antiemetic such as ondansetron would be added when nausea is prominent. The two principles I would teach the family are to take the dose early, because an analgesic taken while the pain is building works far better than one taken once the attack is established, and to cap analgesic use at two or three days a week to avoid medication-overuse headache. [8]

My investigation plan is to image only if a red flag emerges. She meets the ICHD-3 criteria for migraine without aura, her SNNOOP red-flag screen is negative (no thunderclap, no occipital pain, no focal deficit, no papilloedema, no early-morning vomiting, no progressive or under-5 pattern), and her neurological examination is normal, so she does not need a scan, a blood test, or an electroencephalogram. I would measure her disability with the PedMIDAS to quantify the impact on school and to guide the threshold for prophylaxis, and I would review her in clinic with a headache and analgesic diary. [1]

Question 2 (10 marks)

Discuss the stepped approach to prophylaxis for this girl, incorporating the evidence from the CHAMP trial. [6]

I would build the prophylaxis plan in a stepped sequence, beginning with what is not a drug. The foundation is lifestyle medicine: regular sleep, adequate hydration, meals that are not skipped, daily exercise, and the recognition and avoidance of triggers, supported by a headache diary. The prospective cohort by Casanova and colleagues reinforced that embracing these protectors and adhering to healthy lifestyle recommendations is associated with fewer headache days, and these interventions are effective, safe, and free. Because she has more than four headache days a month and has missed school, she is above the threshold at which prophylaxis is considered. [12]

The next and most effective single addition for a girl with frequent attacks is cognitive behavioural therapy. The randomised trial by Powers and colleagues showed that cognitive behavioural therapy added to a preventive drug roughly halved the days of headache and the disability score compared with headache education added to a preventive drug in children and adolescents with chronic migraine, and the effect is durable. I would position behavioural therapy as a core treatment, not an adjunct. [7]

If her attacks remained disabling despite the lifestyle and behavioural platform, I would consider a preventive drug, and I would frame the conversation around the CHAMP trial. The CHAMP trial found that neither amitriptyline nor topiramate was superior to placebo for paediatric migraine, because the placebo response in children is exceptionally high, reaching up to 60 per cent. The 2019 AAN and AHS guideline therefore frames these drugs as options to consider rather than established preventives. If I were to start a drug, I would use amitriptyline at night or topiramate titrated to a weight-based target, counsel the family on the high placebo response and the uncertain drug benefit, and judge the response over eight to twelve weeks before continuing, switching, or weaning. The goal I would set with the family is a return to function and school attendance, not a headache-free child, and the first and most effective intervention is the weaning of the codeine combination that is driving her medication-overuse headache. [6]