Practice Parameter

Systematic review of 166 articles by the American Academy of Neurology101[I] from 1980 to 2003 with an age qualifier of 3-18 years, and a four-tiered scheme of evidence classification (class I-IV) and recommendation (levels A-C, U). Acute treatment recommendations were:

• ibuprofen effective (level A);

• paracetamol (acetaminophen) probably effective (level B);

• sumatriptan nasal spray effective for adolescents (level A);

• inadequate data for subcutaneous sumatriptan (level U).

For preventive treatment:

• flunarizine probably effective (level B); not available in USA;

• insufficient evidence to recommend cyproheptadine, amitriptyline, valproate semisodium (divalproex sodium), topiramate, or levetiracetum (level U);

• pizotifen, nimodipine, and clonidine showed no efficacy (level B); not recommended;

• there is conflicting evidence for the use of propranolol and trazodone (level U).

The review also concluded that there is a need for "multicenter, placebo-controlled clinical trials to assess the safety, tolerability, and efficacy of medications used for the acute and preventive treatment of pediatric migraine.''

The present practice of pediatric headache therapy is based on adult guidelines. According to the US Headache Consortium in 2000,102[I] the adult agents that show the best balance of efficacy, evidence, and adverse effects are amitriptyline, valproate semisodium, propranolol, and timolol. There is lower efficacy and less evidence for aspirin, NSAID, gabapentin, verapamil, other beta-blockers, riboflavin, magnesium, and feverfew. Consensus efficacy is available for cyproheptadine, diltiazem, nortriptyline, and doxepin. No efficacy greater than placebo is present for carbamazepine, indometacin, nifedipine, and lamotrigine.

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