An evidence-based pediatric migraine management guide for clinicians: Treatment thresholds, first-line options, advanced therapies and patient-centered care

Published: July 14, 2025

Pediatric migraine management requires a nuanced approach that differs significantly from adult protocols. While migraine affects up to 10% of children and adolescents, treatment decisions must account for developmental considerations, family dynamics and the substantial placebo effect observed in younger patients. This evidence-based guide synthesizes current best practices for clinicians managing pediatric migraine, from initial prevention decisions through advanced therapeutic options.

Paul H. Gong, M.D., pediatric neurologist and headache medicine specialist with Norton Children’s Neuroscience Institute, affiliated with the UofL School of Medicine, presented this information at “Updates in Pediatrics: Migraines in Children and Teens,” a recent continuing medical education opportunity.

When to initiate preventive treatment

Consider preventive therapy when pediatric patients experience headaches two or more times per week. This threshold differs from adult guidelines, which typically recommend prevention at four or more episodes monthly. The lower pediatric threshold reflects findings from the CHAMP trial, which demonstrated that many standard preventive medications performed no better than placebo in children, highlighting the significant placebo effect in this population.

Core treatment philosophy

Remember that migraine management aims to prevent symptoms, not cure the condition. Migraine is a genetic neurological disorder characterized by brain hyperexcitability. Treatment goals focus on reducing frequency, severity and disability while ensuring effective acute management strategies.

First-line preventive options

Nutraceuticals

These offer excellent safety profiles for hesitant families:

• Vitamin D: Target levels greater than 40 nanograms per milliliter (ng/mL); supplement if less than 30 ng/mL (50,000 units weekly for eight 8 weeks, then 2,000 units daily)
• Riboflavin: 50 milligrams twice daily (split dosing for improved gastrointestinal absorption)
• Coenzyme Q10: 100 milligrams daily (especially beneficial in deficient patients)
• Folate: 400 micrograms via multivitamin

Prescription medications

Amitriptyline and topiramate remain first-line choices with Class A evidence:

• Amitriptyline: 1 milligram per kilogram per day; monitor for sedation, constipation, weight gain
• Topiramate: 2 to 3 milligrams per kilogram per day; watch for paresthesia, decreased appetite, metabolic acidosis

Titration strategy: Start low and increase every two weeks to improve tolerability and adherence.

Advanced treatment options

Botox (onabotulinumtoxin A)

Reserve for chronic migraine patients who have failed two or more preventive medications:

• 31 injections across head, neck, and shoulders
• Every three months; benefits typically seen after second or third treatment
• Well-tolerated in adolescents despite off-label use

Anti-CGRP (calcitonin gene-related peptide) therapies

Monoclonal antibodies (erenumab, fremanezumab, galcanezumab) show promise for patients ages 12 and older:

• Monthly injections with excellent tolerability
• Consider after failure of two standard preventives
• Particularly valuable for nonchronic migraine patients

Gepants (rimegepant, ubrogepant) offer oral acute treatment alternatives to triptans with fewer side effects.

Neuromodulation devices

Increasingly popular nonpharmacological options:

• Nerivio: Remote electrical stimulation device (approved for ages 8 and older)
• GammaCore: Vagal nerve stimulation (approved for ages 12 and older)
• Cefaly/SpringTMS: Transcranial stimulation devices

These require out-of-pocket payment but offer low side effect profiles.

Patient-centered care principles

Effective pediatric migraine management requires:

• Shared decision-making: Present multiple options with clear side effect profiles.
• Holistic assessment: Consider pill-swallowing ability, comorbidities and family preferences.
• Lifestyle optimization: Emphasize hydration, regular meals, sleep hygiene and exercise.
• Comprehensive symptom management: Address nonpain symptoms that often cause significant disability.

The pediatric migraine landscape continues evolving, with promising new therapies on the horizon. Success depends on individualized, family-centered approaches that balance efficacy with tolerability while addressing the multifaceted nature of migraine disability in children and adolescents.