Adolescents receiving the following treatments are more likely than those receiving placebo to be free of headache pain at 2 hours: • Sumatriptan/naproxen OT 10/60 mg (RR 2.95; 95% CI 1.65–5.27; 1 Class I study17), • Sumatriptan/naproxen OT 30/180 mg (RR 2.72; 95% CI 1.51–4.89; 1 Class I study17), • Sumatriptan/naproxen OT 85/500 mg (RR 2.17; 95% CI 1.49–3.16; 1 Class I17 and 1 Class II18 study), • Zolmitriptan NS 5 mg (RR 1.90; 95% CI 1.47–2.46; 1 Class I study15 and 1 Class II study8). Adolescents receiving sumatriptan/naproxen OT 30/180 are possibly more likely than those receiving placebo to be free of phonophobia at 2 hours (RR 1.38; 95% CI 1.07–1.78; 1 Class I study17). No comments have been published for this article. Residency program: Neurology, MD: East Carolina University The AAN is committed to producing independent, critical, and truthful clinical practice guidelines (CPGs). Dr. Licking: acquisition of data, interpretation of data, revising the manuscript. DOI: https://doi.org/10.1212/WNL.0000000000008095, Headache Classification Committee of the International Headache Society, The International Classification of Headache Disorders, 3rd edition (beta version), Clinical Practice Guideline Process Manual, GRADE: an emerging consensus on rating quality of evidence and strength of recommendations, Sumatriptan nasal spray in adolescent migraineurs: a randomized, double-blind, placebo-controlled, acute study, Oral sumatriptan for migraine in children and adolescents: a randomized, multicenter, placebo-controlled, parallel group study, A randomized, double-blind, placebo-controlled study of sumatriptan nasal spray in the treatment of acute migraine in adolescents, Nasal sumatriptan is effective in treatment of migraine attacks in children: a randomized trial, Adolescent Migraine Steering Committee. Authors who serve or have served as AAN subcommittee members or as methodologists (M.O., Y.H.M., T.P., S.P., L.B., D.G., and N.L.) These associated symptoms can be inferred by family report of the child's activities. Children and adolescents receiving 5 or 10 mg of rizatriptan oral disintegrating tablets (ODT) are probably no more likely than those receiving placebo to have a headache pain response at 2 hours (RR 1.07; 95% CI 0.97–1.17; 3 Class II studies9,–,11). Clinicians should prescribe ibuprofen OS (10 mg/kg) as an initial treatment option to reduce pain in children and adolescents with migraine (Level B). Dr. Pringsheim: study concept and design, acquisition of data, analysis or interpretation of data, drafting/revising the manuscript, critical revision of the manuscript for important intellectual content, study supervision. More guidelines and information on Disputes & Debates, Neurology | Print ISSN:0028-3878 The guideline seeks to answer the following clinical question: In children and adolescents with migraine, do acute self-administered treatments, compared with placebo, reduce headache pain and associated symptoms (nausea, vomiting, photophobia, and phonophobia) and maintain headache freedom? From 1993-1998, he had studied at UVA Radiology and Medical Imaging, completing his residency and musculoskeletal fellowship. Dr. There is insufficient evidence to determine whether adolescents receiving the following treatments are more or less likely than those receiving placebo to be free of nausea at 2 hours: • Sumatriptan NS 5 mg (RR 1.19; 95% CI 0.96 to 1.48; 1 Class II study), • Sumatriptan NS 10 mg (RR 1.11; 95% CI 0.97–1.27; 1 Class II study6), • Sumatriptan/naproxen OT 10/60 mg (RR 1.17; 95% CI 1.01–1.35; 1 Class I study17), • Sumatriptan/naproxen OT 30/180 mg (RR 1.10; 95% CI 0.94–1.28; 1 Class I study17). There is insufficient evidence to determine whether children and adolescents receiving the rizatriptan ODT 5 or 10 mg are more or less likely than those receiving placebo to have resolution of photophobia at 2 hours (RR 1.11; 95% CI 0.98–1.25; 1 Class II study10). Adolescents receiving sumatriptan/naproxen OT 85/500 mg are probably no more likely than those receiving placebo to be nausea-free at 2 hours (RR 1.00; 95% CI 0.86–1.16; 1 Class I study17). The information (1) should not be considered inclusive of all proper treatments, methods of care, or as a statement of the standard of care; (2) is not continually updated and may not reflect the most recent evidence (new evidence may emerge between the time information is developed and when it is published or read); (3) addresses only the question(s) specifically identified; (4) does not mandate any particular course of medical care; and (5) is not intended to substitute for the independent professional judgment of the treating provider, as the information does not account for individual variation among patients. Submit only on articles published within the last 8 weeks. Dr. Hester holds bachelor’s and medical degrees from the University of Louisville and a Master of Business Administration degree from Bellarmine University in Louisville. Go to Neurology.org/N for full disclosures. NOTE: All authors' disclosures must be entered and current in our database before comments can be posted. were reimbursed by the AAN for expenses related to travel to subcommittee meetings where drafts of manuscripts were reviewed. Dr. Yonker: study concept, interpretation of data, revising the manuscript. A. Hershey has served on a scientific advisory board for Allergan, XOC Pharma, and Amgen; served as an editor for Headache, Cephalalgia, and the Journal of Headache and Pain; has received compensation from Allergan and MAP Pharma and currently receives compensation from Alder, Amgen, Avanir, Curelator, Depomed, Impax, Lilly, Supernus, and Upsher-Smith for serving on speakers' bureaus and as a medical consultant; has received research support from GlaxoSmithKline for serving as a Local Site PI on a study on pediatric migraine treatment, from the Migraine Research Foundation and Curelator, Inc. for serving as a principal investigator on studies on migraine genomics and diagnosis, and from the National Headache Foundation for serving as a coinvestigator on a study on migraine prognosis; has received grants from the National Institutes of Health/National Institute of Neurologic Disorders and Stroke (NINDS) for serving as a coinvestigator on a study on migraine management, studies on treatment, prognosis, and diagnosis of pediatric chronic migraine and headache, and for serving as a dual principal investigator on a study on amitriptyline and topiramate in the prevention of childhood migraine; and serves as a board member of the American Headache Society. Given the distinct mechanisms of action among medications in the triptan class and the nonsteroidal anti-inflammatory drug (NSAID) class, the addition of an NSAID to a triptan may improve rates of pain response and pain-free status. It is important to learn about the behavioral aspects of self-care that might improve migraine, including healthy habits with lifestyle modification, potential migraine triggers/aggravating factors, and the risk of overusing medication. Migraine is typically accompanied by other symptoms (nausea, vomiting, photophobia, phonophobia) in addition to head pain. AAN limits the participation of authors with substantial conflicts of interest. The authors found 2,482 abstracts relevant to acute or preventive therapy for pediatric migraine. Recommendations Recommendations for the treatment of acute migraine in children and adolescents focus on the importance of early treatment, choosing the route of administration best suited to the characteristics of the individual migraine attack, and providing counseling on lifestyle factors that can exacerbate migraine, including trigger avoidance and medication overuse. The complete practice guideline, including the risk of bias assessment for each study, meta-analysis, methods for analysis of the evidence, and confidence in evidence determinations, is available at https://www.aan.com/Guidelines/home/GetGuidelineContent/977. Antiemetics are available to treat nausea and vomiting related to other pediatric conditions (acute gastroenteritis, postoperative state, chemotherapy)31,32 and may be of benefit for migraine-associated nausea, although no clinical trials specifically evaluating antiemetics for pediatric migraine-associated nausea have been performed. Clinicians should offer an alternate triptan, if 1 triptan fails to provide pain relief, to find the most effective agent to reduce migraine symptoms (Level B). Patients with signs and symptoms of secondary headache, such as sudden change in headache, papilledema, focal deficits, and the additional presence of seizures, require further evaluation beyond a thorough history and physical examination. Although the pathophysiology of migraine is presumed to be the same as in adults, a higher placebo response is observed in children and adolescents, with a lower therapeutic gain measured in clinical trials.39 Patterns of migraine presentation and associated symptoms in children and adolescents evolve into the adult patterns and their shortest headaches may be shorter in duration.1 These factors should be considered when designing clinical trials. Use of the information is voluntary. Methods We performed a systematic review of the literature and rated risk of bias of included studies according to the American Academy of Neurology classification of evidence criteria. Patients respond differently to the same medication. AAN provides this information on an “as is” basis and makes no warranty, expressed or implied, regarding the information. There is high confidence that adolescents receiving oral sumatriptan/naproxen and zolmitriptan nasal spray are more likely to be headache-free at 2 hours than those receiving placebo. Addiction Medicine: The Urgent Need for Trained Physicians Check Out the Proceedings of the 9/26/17 Congressional Briefing. There is insufficient evidence to determine whether adolescents receiving sumatriptan NS 5 mg are more or less likely than those receiving placebo to have a headache pain response at 30 minutes (RR 1.03; 95% CI 0.80–1.32; 1 Class I4 study). M. Yonker has served on a scientific advisory board for AMGEN and for Upsher-Smith Pharmaceuticals; has served as a reviewer for Cephalalgia, Headache, Pediatrics, and the Journal of the Child Neurology Society; has received research support as a primary investigator from AstraZeneca, Allergan, Avanir, and NINDS; has received funding for travel from the American Headache Society for serving as a presenter at the Scottsdale Headache Symposium; and serves as a consultant to Impax. A modified Grading of Recommendations Assessment, Development and Evaluation process3 was used to develop conclusions. According to the FDA, triptans are contraindicated in those with a history of hemiplegic aura or migraine with brainstem aura. Adolescents receiving the following treatments are probably more likely than those receiving placebo to be free of photophobia at 2 hours: • Sumatriptan/naproxen OT 10/60 mg (RR 1.45; 95% CI 1.12–1.87; 1 Class I study17), • Sumatriptan/naproxen OT 85/500 mg (RR 1.44; 95% CI 1.14–1.82; 1 Class I study17). - In the cup: 30 points - In & Out: 10 points Adolescents receiving the following treatments are probably no more likely than those receiving placebo to have relief of vomiting at 2 hours: • Sumatriptan NS 5 mg (RR 1.01; 95% CI 0.98–1.05; 1 Class I4 and 1 Class II6 study), • Sumatriptan NS 20 mg (RR 1.02, 95% CI 0.99–1.05; 1 Class I study4).