Some patients with migraines will seek treatment in in a small study of 32 children and adolescents (Refer-

the ED because of failed home management. The an-
tidopaminergic drugs as well as intravenous ketorolac
have shown benefit in the ED setting (Reference 18).
Prochlorperazine has shown superiority to ketorolac in
a head-to-head study of children 5–18 years old in the
ED setting (Reference 25). Combining these two drug
classes has resulted in increased efficacy (Reference 18).
About 6% to 7% of patients with migraines do not ob-
tain relief from medications in the ED, so they are ad-
mitted to an inpatient service for migraines (Reference
18). A migraine that is a debilitating attack lasting more
than 72 hours is termed status migrainosus (Reference
12). This type of migraine is severe in intensity and is
usually treated in the inpatient setting (References 12,
18). Intravenous dihydroergotamine (DHE) may be
used in a low- or high-dose protocol to stop an intrac-
table migraine. Administered every 8 hours until the
headache ceases or until the maximal dose (15 mg) is
reached, DHE was found to be 97% effective in head-
ache improvement and 77% effective in headache relief
ence 26). Intravenous valproic acid has also been used for
this type of migraine. These are not FDA label-approved
uses in children, but case reports and open-label studies
have shown benefit (Reference 18).
Prophylaxis
Most children do not require prophylactic medications
for migraines. Currently, none of the drugs marketed in
the United States are FDA label approved for prophy-
laxis use in children. In Europe, flunarizine, a calcium
channel blocker, is approved because of several stud-
ies showing its efficacy (Reference 18). The AAN also
supports the use of flunarizine, but availability limits its
use (Reference 5). Current treatment options for pro-
phylaxis in children include cyproheptadine, amitripty-
line, propranolol, valproic acid, and topiramate (Table
2). Cyproheptadine has antiserotonergic effects and
may have calcium antagonistic characteristics (Refer-
ence 18). One study has shown it to be comparable to

Table 2. Medications Used for Migraine Prophylaxis (References 18, 27)

Maximum Contraindications/
Drug Dose Dose per Day Boxed Warnings Drug Interactions
Antihistamine
Cyproheptadine 0.25–1.5 mg/kg 24 mg MAO inhibitors, acute asthma Decrease effects of
or 4–8 mg TID attack, GI tract obstructions, SSRIs; enhance CNS
stenosing peptic ulcer depressant effects
Antidepressant
Amitriptyline 10–50 mg daily MAO inhibitors; U.S. boxed Major 2D6 and minor
at bedtime warning: worsening of 1A2, 2B6, 2C19, 2C9,
depression or suicidal 3A4 substrate; weak
ideations in children with inhibitor of 1A2, 2C19,
depression 2C9, 2D6, and 2E1
ȕ-Blocker
Propranolol 2–4 mg/kg/day or 4 mg/kg/day Asthma, hyperactive lung Major 1A2, 2D6 and
10–40 mg TID or 120 mg disease, sinus bradycardia, minor 2C19, 3A4
heart block greater than first substrate; weak
degree, sick sinus syndrome inhibitor of 1A2, 2D6,
P-glycoprotein
Anticonvulsants
Valproic acid 20–40 mg/kg/day 1000 mg VPA: Liver disease or VPA: Minor 2A6,
(VPA) dysfunction, U.S. boxed 2B6, 2C9, 2C19,
warnings: hepatic failure 2E1 substrate. Weak
(children < 2 years at greatest inhibitor of 2C9,
risk), pancreatitis 2C19, 2D6, 3A4. Weak
inducer of 2A6.
Topiramate 1–10 mg/kg/day 200 mg TOP: None TOP: Weak inhibitor of
(TOP) (usual 50 mg BID) 2C19; weak to moderate
inducer of 3A4
BID = two times/day; CNS = central nervous system; GI = gastrointestinal; MAO = monoamine oxidase; SSRI = selective serotonin
reuptake inhibitor; TID = three times/day.

Migraines ƒ Eiland ƒ 405