Pediatric Migraine
Loren Bonner
Approximately 10% of children ages 5 to 15 years experience a migraine, according to the Cleveland Clinic. Prevalence increases with age, too, with 28% of teenagers having had a migraine.
“Migraine is a progressive disease—there’s evidence for that,” said Richard Wenzel, PharmD. “It’s more difficult to treat as the person gets older. Diagnosing migraine as soon as you can and effectively treating it is important.”
While OTC medications, such as ibuprofen and acetaminophen, are recommended to treat migraine in pediatric patients, and prescription triptans can be a safe option for severe migraine, preventive treatment in this population is slow to catch up.
However, with the 2025 FDA approval of fremanezumab, a calcitonin gene-related peptide (CGRP) antagonist (AJOVY—Teva Pharmaceuticals), younger patients now have a treatment option for prevention. Fremanezumab is approved for children who are at least 6 years old and weigh 45 kilograms or more.
Prevention should be considered if headaches occur frequently for the patient, are severe, and result in significant disability.
One challenge with fremanezumab is making sure patients and caregivers are properly administering the dose at home with the autoinjector. The monthly injection can be given in a physician’s office or at home.
“There is so much patient education needed for new devices,” said Wenzel.
Issues with autoinjector technique and dosing have been problematic, according to Wenzel, frequently leading to underdosing, injection into the wrong site or complete failure to deliver the medication.
Even with fremanezumab as a safe option, Wenzel said overall, more robust migraine research is needed for preventive treatment in pediatric patients.
Screening in the pharmacy
A leading reason a person will seek out a pharmacist is to ask for headache relief.
“Headache is everywhere,” said Wenzel.
Migraine-related disability is determined using an evaluation tool such as the Pediatric Migraine Disability Assessment, a six-question scale that measures migraine impact over 3 months.
Right now, diagnosis of migraine is based on self-reported symptoms. The diagnostic criteria for pediatric migraine is also slightly different than it is for adults.
Mainly, duration is not as long in children, with an attack being as short as 2 hours. For adults, the length is at least 4 hours.
Pharmacies have these tools and can be a place for screening.
“If you do need to see a headache specialist, the screening tool can take patients to that step. And pharmacies are an excellent place for assessing where current therapy is working,” said Wenzel.
Because of the shorter duration of migraine attacks, Wenzel said it’s easy to misdiagnose migraine in pediatric patients and blame it on other factors.
“We need to get on it earlier and identify and effectively treat it early on,” he said.
The goal is to manage the chronic condition and allow patients to function and engage with life.
“Then do that with minimal intervention,” said Wenzel.
Medications are important, too, but he noted they are not the only tool. Nonpharmacological approaches backed by evidence include nutraceuticals or vitamins, including magnesium, riboflavin, and melatonin; noninvasive neuromodulation; and mind-body therapies such as cognitive behavioral therapy, biofeedback treatment, and even mindfulness.
Wenzel noted that children can be more receptive to these approaches than many adults who tend to want a quick fix with a pill. ■
Acute and preventive pediatric migraine treatment guidelines
The American Academy of Neurology has both acute and preventive treatment guidelines for pediatric migraine.
The latest acute and preventive guidelines can be accessed at: www.aan.com/practice/guidelines ■
Pediatric migraine disability assessment (PedMIDAS)
In the past 3 months:
- How many full days of school did you miss because of headaches?
- How many partial days of school did you miss because of headaches?
- How many days did you go to school but functioned at less than one-half your ability because of a headache?
- How many days were you not able to do things at home because of a headache?
- How many days were you not able to participate in other activities because of a headache?
- How many days did you participate in other activities but functioned at less than one-half of your ability because of headaches?
Total the answers of all questions to get the PedMIDAS score.
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PedMIDAS disability grades
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Score
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Grade
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Disability
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0–10
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1
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Little to none
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11–30
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2
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Mild
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31–50
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3
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Moderate
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>50
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4
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Severe
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