British Association for the Study of Headache (BASH: UK)
Membership enquiries: Professor Peter Goadsby
ACUTE DRUG TREATMENTS
What should I use for my daughter’s migraine attacks?
It depends on what sort of migraine and what symptoms she gets. If she has aura, taking something such as ibuprofen as soon as the aura starts is a good option. Even if she does not feel nauseated, taking something to encourage the stomach to empty will tend to make the ibuprofen work faster.
If she does not get aura but her attack starts with a headache, the same mix should work well if it is taken early enough.
Should I try ibuprofen or paracetamol to ease the migraine headache my daughter gets?
Either has the potential to work, provided a high enough dose is taken and it is taken early enough. Migraine is an inflammatory process, so ibuprofen should work better than paracetamol. Taking both together may work better than either one alone. Everyone is different, and the best treatment is the one that works best for your daughter – and you won’t know which until she tries them both.
My son gets quite bad nausea and vomiting. What can he try to help relieve these symptoms?
The best option is what is referred to as a gastric-emptying antiemetic – it helps the stomach to empty and should reduce the chance of vomiting. There are two drugs that can be used but domperidone is the one preferred in children. The dose is calculated on the basis of body weight and can be given as a ‘suspension’ (a liquid) as well as a tablet.
The alternative is metoclopramide, but this is best avoided if your son is under the age of 20 years unless no other option is effective. It can be given in the form of tablets, suspension or injection and, as with domperidone, the dose is calculated according to his body weight.
I would describe my son as being large for his age. Is there a right or wrong dose of ibuprofen to treat his migraine?
The right dose of ibuprofen is the one that works and relieves the headache quickly and completely. There are, of course, dosage guidelines for children in different age groups:
• In 1- to 2-year-olds: 50 mg, three, or four times a day
• In 3- to 7-year-olds: 100 mg, three, or four times a day
• In 8- to 12-year-olds: 200 mg, three, or four times a day. If he is large for his age, I would be inclined to calculate the dose on the basis of his body weight – if you know how much he weighs. The dose is 20–30 mg per kg, split into three or four doses in the day.
Remember that you can use ibuprofen in children under the age of 16, but not aspirin. If ibuprofen does not work, try paracetamol or go back to your doctor for more advice.
I have found that my daughter’s headache gets better with the first dose of ibuprofen but always comes back. Can I repeat the dose?
Yes, you can. She can take a dose every four to six hours, depending on how much she takes each time. The first dose should be the highest, and each subsequent dose could be slightly lower. The total dose that can be taken over any 24-hour period depends on her age and weight, and this total dose can help you calculate the best dose mix.
I use paracetamol for my child’s headache – is there a right dose? Can I give her too much?
As with ibuprofen you need to use the right dose of paracetamol soon enough in the headache phase of a migraine attack. The correct dose is decided on the basis of age, or body weight if under the age of 3 months, taking no more than four doses in each 24-hour period:
• 3 months to 1 year: 60 to 120 mg every 4 to 6 hours
• 1 to 5 years: 120 to 250 mg every 4 to 6 hours
• 6 to 12 years: 250 to 500 mg every 4 to 6 hours
If the child is under 3 months, the dose is calculated using the formula of 10 mg per kg body weight.
How can I tell that my son has the best treatment for his migraine?
That rather depends on how you define ‘best treatment’. The ‘best’ is usually the one that works the quickest, takes the headache away completely, does not allow the headache to come back during the next 24 to 48 hours, and causes few or no side effects.
There is no ‘best’ option to fulfill all these parameters but a suitable compromise should exist if you seek it out. Different people respond to different drugs and drug combinations and the best is the one that gives your son the best compromise.
My son’s treatment seems to work better at the weekend, rather than if an attack occurs at school. Why is that?
This is a difficult question to answer absolutely but treating migraine effectively is all about getting the medication on board quickly. It is generally felt that it may be easier to get treatment on board quickly at home than at school. Access in a school environment may be delayed by needing to get at the medication and also getting water with which to take it. It may also be harder at school to find a quiet place for a short period to allow the medication to take hold.
Why do the pills seem to work better for some attacks rather than others?
Timing is everything when it comes to taking treatment for migraine. ‘If I take my tablets quickly enough’ is a frequently heard phrase. The earlier pills are taken, the more effective they are in treating the attack. Early treatment tends to get rid of the headache more quickly and means it is less likely to recur in the next 24 to 48 hours.
There are other factors that come into play, and they tend to vary from person to person. The relevant factors may well reflect where the person’s migraine threshold is at the time that the attack is triggered. Another difficulty with youngsters is that the attack may be much shorter than is seen in adults, so the criteria used to assess the response may well not be valid or relevant. If the attack is shorter on occasion, the perception is that the treatment worked better, whereas the attack was settling anyway, regardless of the treatment.
Are there any right or wrong tablets for my son to take for his migraine?
The ‘right’ tablet is the one that works well in relieving all the symptoms of the migraine attack and stops it from coming back. The ‘wrong’ tablet is the one that does not relieve the symptoms of the attack or causes unacceptable side effects. Trial and error will discover the ones that help and the ones that don’t.
My doctor said that triptans are not licensed for use in children. What does that mean?
Drugs have to go through a formal approval process before they can be prescribed to treat specified conditions. This occurs after their effectiveness and safety have been assessed in drug trials. The process looks at what conditions a drug can be used to treat and for what age groups it can be prescribed.
Drugs can also be prescribed in an ‘unlicensed’ way, or ‘off licence’. This means that experience and common usage have led to a drug being used for other conditions or age groups. Triptans were originally tested only with adults, and are used safely and effectively by them. Recently, however, two triptans have been licensed for use in 12- to
18-year-olds and this would tend to suggest that all of them can probably be used safely in this age group.
How can I decide which triptan to give to my daughter when only two of them are licensed for children?
The triptan to use is the one that works the best. Sumatriptan adolescent nasal spray and zolmitriptan are currently licensed for use in 12- to 18-year-olds, so try those first. If they do not work as well as expected or hoped for, try the others in turn. You will then find one that works in the way you are looking for.
Is it safe to use something that is not licensed?
Using drugs that are not licensed is possible, and in fact may not be that uncommon. It will depend on what aspect of the licence is actually being ‘ignored’. With triptans, using a drug ‘off licence’ usually relates to the age of the person taking the drug. This is the only area where it is reasonable to consider using a triptan in someone under the age of 12 for sumatriptan adolescent nasal spray and zolmitriptan, and under the age of 18 for the other triptans.
It is felt that these rules of age can be broken, provided that the responsible adult, be this a parent or guardian, gives informed consent. There is a need to balance the theoretical risk of using a triptan in these age groups against the benefit in terms of improved quality of life and reduced time off school or work.
How old do you have to be to take triptans?
Age is a relative thing but according to the licence you should be over the age of 12 to take sumatriptan adolescent nasal spray and zolmitriptan, and over the age of 18 for the other triptans. I take sumatriptan nasal spray and I noticed that the strength is 20 mg but the nasal spray my teenage daughter has been given is only 10 mg. Will hers work as well?
The form of sumatriptan licensed for teens is the ‘adolescent nasal spray’, which is a dose of 10 mg, whereas the adult dose for the nasal spray is 20 mg. The research evidence suggests it should work as well. If you and your daughter feel that it does not offer the necessary benefit, it is reasonable to ask her doctor if she can try the adult version to see if it is any better.
I use zolmitriptan for my migraines. Why can’t my kids use the same if they get migraine?
They can now, if they are 12 or over, because zolmitriptan is one of the two triptans that have been licensed for use between the ages of 12 and 18. Your doctor will probably want to check this out, and can do so by looking it up in a reference book known as the BNF. The BNF is the British National Formulary, which lists all the drugs available in the
If sumatriptan adolescent nasal spray and zolmitriptan don’t work for my daughter, and they are the only triptans that are licensed for adolescents, can we try one of the other triptans?
Yes, you could but you need to talk to your doctor or specialist so that you can discuss the alternatives available and choose which one your daughter wants to try next. They are all worth trying but she will need to treat three consecutive attacks with any given triptan to assess how effective each one is. It is about informed decision-making and making you, as the parent or guardian, aware of the relevant safety issues and concerns.
My doctor has given me lots of information about sumatriptan and zolmitriptan. What other triptans are there?
There are seven different triptans in all, the other five being almotriptan, eletriptan, frovatriptan, naratriptan and rizatriptan; they come in a variety of forms: tablets, wafers or ‘melts’, nasal sprays and injections. There are pros and cons to each and they each work differently in different people. Trial and error is the only way to find out which one works for your child.
If the triptan eases the headache but doesn’t take it away, what else can my daughter try to get rid of her migraine?
She could try the same triptan at a higher dose, if one is available, or a different triptan. All triptans react differently in different people, so all are worth trying to find which works best. If the various triptan options do not work on their own, it is worth your daughter trying taking an anti-inflammatory such as ibuprofen or a simple painkiller such as paracetamol at the same time as the triptan.
It may be that taking an anti-nausea drug such as domperidone (in preference to metoclopramide) may make the triptan more effective. If this is not enough, a mix of triptan, ibuprofen, and domperidone may be needed. It is all about looking at the full range of options out there and ringing the changes until you find what works. Your doctor paediatrician or specialist nurse will be able to provide the necessary advice, information and support needed.
If there are seven triptans, is any one better than the others?
Not really – they all have the ability to work well if taken at the right time at the right dose. Different drugs are ‘best’ in different people, and what is best for one person may not be best for another. The choice is complex and based on a variety of factors, including speed of onset (how quickly the treatment works), sustained pain-free response (the headache going away and staying away) and low side effects (not making you feel any worse than you do already).
