1. Managing Migraine

2. Firstly is the Diagnosis correct? Worrying features: Worsening headache with fever Rapid onset (previously referred to as 'thunder clap') Associated neurological deficit, vomiting or cognitive dysfunction LOC Personality change Triggered by cough, valsalva, sneeze or posture Within 3/12 of head injury Ask about immunodeficiency and/or previous malignancy regardless of whether CNS was involved

3. If history points towards migraine: Use a headache diary for 6-8 weeks: record frequency/duration, associated symptoms e.g. aura, precipitants, medications taken. A migraine in young people (12-17 as per NICE) is: Often associated with throbbing or banging pain and light sensitivity It may be either unilateral or bilateral An aura (flickering lights, sensory symptoms, speech disturbance) may or may not co-exist Lasts up to 72 hours

4. What investigations are appropriate If none of the concerning features in slide 2 are present and symptoms fit with migraine then no neuroimaging should be carried out-do not use for 'reassurance' Obviously onward referral and neuroimaging for those with atypical features

5. Management Firstly be clear about the diagnosis and acknowledge significant impact that migraine can have Provide written information Acute Episodes: Offer combination therapy; an NSAID plus triptan or paracetamol plus triptan often works well Young people should be offered a nasal triptan over an oral triptan (only nasal sumatriptan is marketable to <18s) If monotherapy is preferred choose the option which works best i.e. either paracetamol, NSAID or triptan. An antiemetic can be offered in addition for e.g metoclopramide Do NOT offer opioids If oral options fail then consider a non-oral NSAID/triptan and non- oral preparation of metoclopramide

6. Prophylaxis: Discuss the benefits Initiate either propranolol or topiramate (topiramate is associated with fetal malformations and propranolol is often preferable) If both are ineffective consider gabapentin (in recent trials gabapentin has been found to be very effective; potential to become 1 st line) Gabapentin dose can be escalated to up to 1200mg/day Review decision to continue prophylaxis after 6 months

7. Systematic review by El Chammas et al (2013) considered effectiveness and safety of prophylactic measures in children and young people RCT's of headache medication compared with placebo in children with migraine less than 18 years old (note small number of children in the studies) Topiramate more effective than placebo at reducing number of headaches per month Clonidine, propranolol, piracetam, pizotifen, sodium valproate and fluoxetine were NOT more effective than placebo Sodium valproate and topiramate were associated with more side effects than placebo

8. Non-Pharmacological Options Powers et al (2013) carried out a RCT considering CBT with amitriptyline vrs headache education with amitriptyline for children aged 10-17 with chronic migraine The CBT arm proved more successful at reducing headache frequency Small study size and the use of amitriptyline alongside both interventions makes study difficult to interpret Note NICE does not currently advise amitriptyline NICE does not advise CBT Larger RCTs needed

9. In general once migraine diagnosis reached: Acute episodes managed with combination paracetamol & triptan or NSAID & triptan or monotherapy (paracetamol, NSAID, Triptan) if patient prefers Prophylaxis: 1 st line propranolol/topiramate 2 nd line gabapentin Review decision to continue prophylaxis at regular intervals (6 monthly) May be future role for other agents and non- pharmacological interventions 

10. 1. http://www.nice.org.uk/guidance/cg150/chapter/1- recommendationshttp://www.nice.org.uk/guidance/cg150/chapter/1- recommendations 2. El-Chammas K, Keyes J et al. Pharmacologic Treatment of Pediatric Headaches A Meta-analysis. JAMA Pediatr. 2013;167(3):250-258. doi:10.1001/jamapediatrics.201 3. Powers SW, Susmita M et al. Cognitive Behavioral Therapy Plus Amitriptyline for Chronic Migraine in Children and Adolescents A Randomized Clinical Trial. JAMA. 2013;310(24):2622-2630. doi:10.1001/jama.2013.282533.