Evidence
Alert

“Triptans” can relieve migraines in children and adolescents

Triptans, a migraine medication, relieve migraine headache completely within two hours compared to placebo. Ibuprofen was also effective but less well studied. This review was also reassuring in that any side effects of treatment were mild.

Most evidence identified in this Cochrane review was for sumatriptan, a commonly prescribed treatment for adults, compared to placebo or dummy pills. A few studies examined other triptans or other painkillers, such as ibuprofen or paracetamol against placebo in children and adults.

The findings support current guideline recommendations to prescribe nasal triptans for migraine in adolescents. Only nasal preparations are currently licensed for adolescents, whereas oral administration and use for children under 12 years, is an ‘off-label’ use. There were some mild adverse effects in the triptan groups that highlight the need for an informed discussion between clinicians and parents or patients and monitoring in this group.

Why was this study needed?

Migraines affect about 1 in 10 children of school age. Symptoms are similar to migraine in adults, with headache, nausea, vomiting and light sensitivity, but attacks are usually shorter, coming on quickly and lasting only a few hours. Young migraine sufferers may miss enough school to affect their education.

The number of migraines can be lessened by avoiding triggers, such as certain foods, but preventive treatments used for adults may not be suitable for children. The usual approach in children and young people is to treat the symptoms of migraine when they appear with pain-relief medications.

This systematic review is one of the few to look at the different adult treatments for acute migraine symptoms in under 17s.

What did this study do?

This Cochrane systematic review identified 29 randomised controlled trials comparing different migraine medications against placebo in 9158 children and adolescents aged eight to 15. Most studies (24) investigated the triptan group of painkillers, with half of all trials looking at sumatriptan specifically. Few studies looked at other treatments. The main outcome of interest was pain-relief by two hours.

Data quality was low to moderate: the risk of bias was judged to be low or unclear but there was inconsistency and imprecision in much of the data. Most of the included studies were sponsored by drug manufacturers (19 out of 27) and the authors reported some trial data were not available, which may affect the reliability of the results.

What did it find?

  • Triptans were more effective than placebo at relieving headache completely. For one to be pain free at two hours, six adolescents will need to be treated (relative risk [RR] 1.32, 95% confidence interval [CI] 1.19 to 1.47; 21 studies) and 13 children (RR 1.67, 95% CI 1.06 to 2.62; 3 studies). Nasally administered triptans were more effective against placebo when compared to oral triptans against placebo in two studies.
  • Ibuprofen was better than placebo at giving pain-relief by two hours in two small studies in children (RR 1.87, 95% CI 1.15 to 3.04), but no evidence for effect in a single study in adolescents. Paracetamol was not superior to placebo in one study in children. There were no studies in adolescents.
  • Sumatriptan plus naproxen (a non-steroidal anti-inflammatory, NSAID) was superior to placebo in one large study in 683 adolescents (RR 3.25, 95% CI 1.78 to 5.94).
  • There was an increased risk of minor adverse events in adolescents taking triptans (Risk difference 0.13, 95% CI 0.08 to 0.18) – with an estimated one person affected for every eight treated – but no risk increase in under 12s. There was no significant difference in adverse events between placebo groups and paracetemol, ibuprofen or sumatriptan plus naproxen.

What does current guidance say on this issue?

NICE guidance on headaches in over-12s recommends treating migraine symptoms with an oral triptan and an NSAID, or an oral triptan and paracetamol. Patient preference can be considered, and a nasal triptan may be preferred for young people aged 12 to 17.

When prescribing triptans, NICE recommend starting with the lowest price option, then switching to another if that proves ineffective. Anti-sickness medications are normally also needed alongside to manage nausea and vomiting.

What are the implications?

The largest body of evidence in this review was for triptans – the mainstay of migraine treatment in adults – finding that they were more effective than placebo in children and adolescents. Nasal triptans were more effective than oral triptans, supporting NICE guidance. There were fewer studies assessing other painkillers such as ibuprofen or paracetamol.

All studies compared treatments with placebo rather than with each other, so we cannot compare effects between drugs.

For clinicians, the choice of triptan medication may be guided by factors such as patient preference, route of delivery, or palatability. The researchers say that a parent who has already responded well to one of the medications themselves may be more likely to request that medication for their child.

 

Citation and Funding

Richer L, Billinghurst L, Linsdell MA, et al. Drugs for the acute treatment of migraine in children and adolescents. Cochrane Database Syst Rev. 2016;4:CD005220.

Cochrane UK and the Pain, Palliative and Supportive Care Cochrane Review Group are supported by NIHR infrastructure funding.

 

Bibliography

NICE. Headaches in over 12s: diagnosis and management. CG150. London: National Institute for Health and Care Excellence; 2012.

The migraine trust. Home page. London: The migraine trust; 2016.

The migraine trust. Young sufferers. London: The migraine trust; 2016.

Migraine action. Migraine information. Leicester: Migraine action; 2016.

Produced by the University of Southampton and Bazian on behalf of NIHR through the NIHR Dissemination Centre

 

Definitions

The individual triptans included in this review were almotriptan, eletriptan, naratriptan, rizatriptan, sumatriptan and zolmitriptan.

An unlicensed medicine is a medicine that does not have a UK marketing authorisation.

An off-label medicine is a medicine with an existing UK marketing authorisation that is used outside the terms of its marketing authorisation, for example, by indication, dose, route or patient population.

 

Commentaries

Expert commentary

Although over 10% of children and adolescents suffer with migraine, the majority go unrecognised and untreated. Paracetamol and ibuprofen, together with a prokinetic is a good starting point. It is reassuring that the safety profile of triptans is confirmed, however, only the nasal preparation of sumatriptan is licensed and only for those over 12 years of age. Nevertheless, the BNF lists oral sumatriptan from the age of six years upwards for off-licence use. GPs should feel confident to prescribe oral triptans above the age of 12 but prescribing in a younger group is best left to specialist practice. An important practical point is that failure of response to one triptan is not a class effect.

Dr David Kernick, GP with a special interest in headache, Exeter

Expert commentary

The need for more research on the acute treatment of migraine in children and adolescent has been shown clearly in this systematic review. Conducting clinical trials in young children can be challenging and more so if the drugs in question are old and well established. Research on paracetamol and ibuprofen is needed not only to establish their efficacy, but also to identify the optimum dosages. Nasal sumatriptan and other triptans (to a lesser degree) are shown here to provide good options in the treatment of migraine in adolescents, but further research is need for their role in younger children.

Dr Ishaq Abu-Arafeh, Consultant in Paediatrics and Paediatric Neurology, Royal Hospital for Children, Glasgow