Effectiveness and safety of migraine prophylaxis in children

For preventive migraine treatments in children, which medications are effective and safe? A network meta-analysis provides insights.

Prevention at a glance: What actually works?

A total of 45 clinical trials with 3,771 participants were evaluated. Various prophylactic therapies were investigated for their effectiveness compared to placebo. The following aspects were looked into:

Pregabalin and topiramate: Leaders in seizure control

Compared to placebo, the following active ingredients significantly reduced the frequency of migraine attacks:

Pregabalin was particularly effective, reducing attack frequency by 62% compared to placebo. However, due to the limited number of studies, the significance is limited. A secondary analysis suggests that there is an additive benefit of vitamin D3 and riboflavin: In combination with pregabalin, an even greater reduction in migraine frequency could be achieved than with pregabalin monotherapy.

Other active ingredients with high efficacy in reducing seizure frequency are topiramate in combination with vitamin D3 and levetiracetam.

Flunarizine and α-lipoic acid: High responder rates

Four medications showed a good response rate of at least 50%:

The combination of flunarizine and α-lipoic acid proved particularly effective.

Reduction of pain intensity: Propranolol and cinnarizine score highly

Pain intensity was assessed using a self-assessment. The combination of cinnarizine and propranolol proved particularly effective. Significant effects on pain intensity were also shown by:

Here, too, data suggest that supplementing with vitamin D and riboflavin could increase the effectiveness of pregabalin therapy.

No effects on quality of life and duration of episodes

Although some medications reduced attack frequency, the meta-analysis showed no significant effect on quality of life or daily functioning. Possible reasons could be insufficient study duration or non-standardized measurement methods. However, the limited number of studies on individual active ingredients limits the significance of these results. No significant benefit was found for any of the medications studied regarding the duration of migraine attacks.

Safety aspects: Adverse effects primarily with amitriptyline

The safety profile was analyzed in 30 studies. An increased risk of side effects was particularly evident with:

Conclusion: Optimizing Migraine Prophylaxis in Children

In this analysis, pregabalin and topiramate demonstrated above-average efficacy in migraine prevention in children and adolescents. Interestingly, the finding that additional therapy with vitamins can be beneficial in this setting.

The meta-analysis also provides important evidence of ineffective medications: Melatonin has not been shown to be effective in young patients.

Despite these findings, limitations exist, primarily due to the limited data on individual active ingredients and small study populations. Therefore, the research group recommends that levetiracetam, cinnarizine, and flunarizine in particular be investigated more closely in future studies, as data on these substances are currently limited.

Source
  1. Kohandel Gargari O, Aghajanian S, Togha M, et al. Preventive Medications in Pediatric Migraine: A Network Meta-Analysis. JAMA Netw Open. 2024;7(10):e2438666. doi:10.1001/jamanetworkopen.2024.38666