Prophylactic treatment of pediatric migraine.

BACKGROUND: Migraine occurs in 3% to 5% of young children and up to 18% of adolescents. Management requires a tailored regimen of pharmacological and behavioral measures that consider the headache burden and disability. Patients with frequent or disabling attacks (or both) may warrant preventive agents.
OBJECTIVE: To investigate the patterns of prophylactic treatment of pediatric migraine within one pediatric neurology practice.
METHODS: All charts of patients diagnosed with headache (International Classification of Diseases [ICD] code 784.0) and migraine (codes 346.0, 346.1, and 346.2) during January 2001 July 2001 were retrospectively reviewed to identify diagnosis, demographics, medical decision making, rationale for treatment selections, and outcome assessments. Migraine was diagnosed according to the 1997 proposed pediatric migraine revisions to the International Headache Society.
RESULTS: Charts of 250 children and adolescents, aged 3.2 to 18 years (mean, 12), were reviewed. One hundred twenty-six (50%) were prescribed prophylaxis, along with intermittent analgesic agents. Mean age of those provided with daily prophylaxis was 12.4 years (range, 3.9 to 18), and the mean age of those managed with intermittent therapies was 11.5 years. Preventive agents included amitriptyline (n = 73), cyproheptadine (n = 30), propranolol (n = 8), valproic acid (n = 3), naproxen (n = 3), nimodipine (n = 3), imipramine (n = 3), and topiramate (n = 3). Amitriptyline was the most commonly prescribed agent (58%). Ten patients initially treated with other agents were changed to amitriptyline. Fifteen patients required dosing adjustments, 2 stopped treatment, and 7 changed to other agents for lack of efficacy. Mean headache frequency before treatment was 10.9 per month (range, 4 to 15). After treatment, the mean headache frequency decreased to 4.1 per month (range, 0 to 12), a decrease of 62.4% (n = 54). The overall positive response rate was 89%. Cyproheptadine was the second most commonly prescribed agent (mean age, 8.8 years). Thirty patients were initially treated, 5 later changed to cyproheptadine, 6 required dosage changes, 5 changed to other agents for lack of efficacy, and 1 stopped treatment. Mean headache frequency before treatment was 8.4 per month (range, 4 to 15) and following treatment decreased to 3.75 per month (range, 0 to 12), a decrease of 55.3%. The overall positive response rate was 83%.
CONCLUSIONS: Fifty percent of patients with migraine were prescribed daily prophylactic medicines, reflecting a referral bias. The most commonly prescribed agents were amitriptyline (preferred for the older patients) and cyproheptadine (preferred for the younger patients). The overall positive response rates were 89% for amitriptyline and 83% for cyproheptadine during a 6-month follow-up. Headache frequencies were reduced with amitriptyline by 62% and with cyproheptadine by 55%. Long-term follow-up of this population is ongoing, and prospective studies are needed.