MONTREAL — Ibuprofen significantly alleviated children's headache symptoms compared with placebo, according to findings from a metaanalysis of randomized controlled trials that focused on drug therapy for pediatric migraines, Dr. Lori L. Billinghurst said at the 10th International Child Neurology Congress.
Of more than 4,000 possible inclusions identified from six electronic bibliographic databases, 14 studies met all inclusion criteria. Two randomized controlled trials (RCTs) demonstrated that ibuprofen significantly alleviated headache symptoms, provided complete headache relief, and prevented headache recurrence compared to placebo; no benefits, however, were found for acetaminophen or dihydroergotamine compared to placebo. In one RCT, the dopamine antagonist prochlorperazine was more effective than the NSAID ketorolac, said Dr. Billinghurst, a neurology resident at the University of Alberta, Edmonton.
As a group, the triptans were better than placebo for alleviating headaches (RR 1.13; 95% CI 1.06, 1.20) and providing complete headache relief (RR 1.34; 95% CI 1.18, 1.52), with sumatriptan the only effective individual medication of the class. Rizatriptan improved headache relief compared with standard care.
The metaanalysis also showed a very high placebo rate of 47% for headache alleviation and 21% for headache relief, said Dr. Billinghurst. Because this problem has become a major impediment for clinical trials, new and innovative study designs are needed to evaluate the efficacy of therapies.
Taken together, these reports reveal disconnection between evidence and practice for acute treatment of pediatric migraines. For instance, there is no evidence to support the use of opiates—but opiates are offered, especially in adult emergency departments. On the other hand, there is evidence to support the use of triptans, especially intranasal sumatriptan, for acute migraine relief—but these were not options in either the adult or pediatric emergency department setting. The evidence also suggests that ibuprofen is a better choice than acetaminophen for pediatric migraine. The high placebo rate noted in RCTs suggested that no treatment or just supportive treatment (e.g., intravenous fluids) may sometimes be an appropriate path to follow.
The results also underscore the need for practice management guidelines to ensure consistency of diagnosis and treatment of pediatric migraines in the acute setting, as well as to highlight the need for more RCTs to assess the safety, tolerability, and efficacy of medications such as dopamine antagonists for migraines in children.