Abstract
Studies on the acute treatment of migraine in children and adolescents are rare and difficult to design. In particular, the high placebo response in some trials makes it difficult to prove efficacy of a verum drug. All available placebo-controlled trials on the acute migraine treatment in children and adolescents with a triptan were analyzed with respect to different end points (rate of pain free and pain relief at 2 hours; rate of adverse events). We identified 6 crossover and 11 parallel group trials. Although the trials were heterogenous with respect to the triptans and the dosage, pooled data were calculated. The pooled responder rate of triptans for 2 hours pain free was 36.0 % in crossover trials (significant difference to placebo with 17.7 %) and 32.5 % in parallel group trials (significant difference to placebo with 26.3 %). Triptans also showed a significantly higher pain relief rate at 2 hours than placebo both in crossover and parallel group trials. The rate of adverse events was significantly higher after triptans than after placebo. However, triptans were well tolerated in all trials. At least 1 trial with significant efficacy was found for sumatriptan (10–20 mg nasal spray), zolmitriptan (2.5–5 mg tablet), rizatriptan (5–10 mg tablet), and almotriptan (12.5–25 mg tablet). Placebo rates for efficacy were considerably lower in crossover trials than in parallel group trials. This analysis suggests that parallel group trials on the acute treatment of migraine in children and adolescents with a triptan show a very low therapeutic gain because of a high placebo rate. The verum response rates, however, are very similar to those seen in adulthood trials. However, there is sufficient evidence that at least some triptans are efficacious even in childhood and adolescence.
Similar content being viewed by others
References
Papers of particular interest, published recently, have been highlighted as: • Of importance
Hämäläinen ML, Hoppu K, Valkeila E, Santavuori P. Ibuprofen or acetaminophen for the acute treatment of migraine in children: a double-blind, randomized, placebo-controlled, crossover study. Neurology. 1997;48:103–7.
Lewis DW, Kellstein D, Dahl G, Burke B, Frank LM, Toor S, et al. Children’s ibuprofen suspension for the acute treatment of pediatric migraine headache. Headache. 2002;42:780–6.
Evers S, Rahmann A, Kraemer C, Kurlemann G, Debus O, Husstedt IW, et al. Treatment of childhood migraine attacks with oral zolmitriptan and ibuprofen. Neurology. 2006;67:497–9.
Überall MA, Wenzel D. Intranasal sumatriptan for the acute treatment of migraine in children. Neurology. 1999;52:1507–10.
Winner P, Rothner AD, Saper J, Nett R, Asgharnejad M, Laurenza A, et al. A randomized, double-blind, placebo-controlled study of sumatriptan nasal spray in the treatment of acute migraine in adolescents. Pediatrics. 2000;106:989–97.
Ahonen K, Hämäläinen ML, Rantala H, Hoppu K. Nasal sumatriptan is effective in the treatment of migraine attacks in children. Neurology. 2004;62:883–7.
Lewis D, Ashwal S, Hershey A, Hirtz D, Yonker M, Silberstein S. American Academy of Neurology. Quality Standards Subcommittee; Practice Committee of the Child Neurology Society. Practice parameter: pharmacological treatment of migraine headache in children and adolescents: report of the American Academy of Neurology Quality Standards Subcommittee and the Practice Committee of the Child Neurology Society. Neurology. 2004;63:2215–24.
Evers S, Kropp P, Pothmann R, Heinen F, Ebinger F. Therapie idiopathischer Kopfschmerzen im Kindes- und Jugendalter. Nervenheilkunde. 2008;27:1127–37.
Evers S, Afra J, Frese A, Goadsby PJ, Linde M, May A, et al. EFNS guideline on the drug treatment of migraine—revised report of an EFNS task force. Eur J Neurol. 2009;16:968–81.
Lewis DW, Winner P, Wasiewski W. The placebo response rate in children and adolescents. Headache. 2005;45:232–9.
Winner P. Overview of pediatric headache. Curr Treat Options Neurol. 2004;6:471–87.
Evers S, Marziniak M, Frese A, Gralow I. Placebo efficacy in childhood and adolescence migraine: an analysis of double-blind and placebo-controlled studies. Cephalalgia. 2009;29:436–44.
Lewis DW, Winner P, Hershey AF, Wasiewski WW. Adolescent Migraine Steering Committee. Efficacy of zolmitriptan nasal spray in adolescent migraine. Pediatrics. 2007;120:390–6.
Ahonen K, Hämäläinen ML, Eerola M, Hoppu K. A randomized trial of rizatriptan in migraine attacks in children. Neurology. 2006;67:1135–40.
Hämäläinen M, Hoppu K, Santavuori P. Sumatriptan for migraine attacks in children: a randomized placebo-controlled study. Do children with migraine respond to oral sumatriptan differently than adults? Neurology. 1997;48:1100–3.
Winner P, Linder S, Lipton RB, Almas M, Parsons B, Pitman V. Eletriptan for the acute treatment of migraine in adolescents: results of a double-blind, placebo-controlled trial. Headache. 2007;47:511–8.
Rothner AD, Wasiewski W, Winner P, Lewis D, Stankowski J. Zolmitriptan oral tablet in migraine treatment: high placebo responses in adolescents. Headache. 2006;46:101–9.
Winner P, Rothner D, Wooten J, Webster C, Ames M. Sumatriptan nasal spray in adolescent migraineurs: a randomized, double-blind, placebo-controlled, acute study. Headache. 2006;46:212–22.
Linder SL, Mathew NT, Cady RK, Finlayson G, Ishkanian G, Lewis DW. Efficacy and tolerability of almotriptan in adolescents: a randomized, double-blind, placebo-controlled trial. Headache. 2008;48:1326–36.
Visser WH, Winner P, Strohmaier K, Klipfel M, Peng Y, McCarroll K, et al. Rizatriptan protocol 059 and 061 study groups. Rizatriptan 5 mg for the acute treatment of migraine in adolescents: results from a double-blind, single-attack study and 2 open-label, multiple-attack studies. Headache. 2004;44:891–9.
Winner P, Lewis D, Visser WH, Jiang K, Ahrens S, Evans JK. Rizatriptan Adolescence Study Group. Rizatriptan 5 mg for the acute treatment of migraine in adolescents: a randomized, double-blind, placebo-controlled study. Headache. 2002;42:49.
Rothner A, Edwards K, Kerr L, Debussy S, Asgharnejad M. Efficacy and safety of naratriptan tablets in adolescent migraine. J Neurol Sci. 1997;150:S106.
Korsgard AG. The tolerability, safety and efficacy of oral sumatriptan 50 mg and 100 mg for the acute treatment of migraine in adolescents (Abstract). Cephalalgia. 1995;15 Suppl 16:99.
• Ho TW, Pearlman E, Lewis D, Hämäläinen M, Connor K, Michelson D, et al. The Rizatriptan Protocol 082 Pediatric Migraine Study Group. Efficacy and tolerability of rizatriptan in pediatric migraineurs: Results from a randomized, double-blind, placebo-controlled trial using a novel adaptive enrichment design. Cephalalgia. 2012;32:750–65. This study presents a unique design (so-called enriched design) to avoid problems caused by the high placebo responses in childhood and adolescence migraine trials.
Winner P, Rothner AD, Putnam DG, Asgharnejad M. Demographic and migraine characteristics of adolescents with migraine: Glaxo Wellcome clinical trial’s database. Headache. 2003;43:451–7.
Derosier FJ, Lewis D, Hershey AD, Winner PK, Pearlman E, Rothner AD, et al. Randomized trial of sumatriptan and naproxen sodium combination in adolescent migraine. Pediatrics. 2012;129:e1411–20.
MacDonald JT. Treatment of juvenile migraine with subcutaneous sumatriptan. Headache. 1994;34:581–2.
Linder SL. Subcutaneous sumatriptan in the clinical setting: the first 50 consecutive patients with acute migraine in the pediatric neurology office practice. Headache. 1996;36:419–22.
Linder SL, Dowson AJ. Zolmitriptan provides effective migraine relief in adolescents. Int J Clin Pract. 2000;54:466–9.
Macedo A, Farre M, Banos JE. A meta-analysis of the placebo response in acute migraine and how this response may be influenced by some characteristics of clinical trials. Eur J Pharmacol. 2006;62:161–72.
Bendtsen L, Mattson P, Zwart JA, Lipton RB. Placebo response in clinical randomized trials of analgesics in migraine. Cephalalgia. 2003;23:487–90.
Harth SC, Johnstone RR, Thong YH. The psychological profile of parents who volunteer their children for clinical research: a controlled study. J Med Ethics. 1992;18:86–93.
Caldwell PH, Butow PN, Craig JC. Parents' attitudes to children's participation in randomized controlled trials. J Pediatr. 2003;142:554–9.
Marziniak M, Haag G, May A, Lampl C, Sandor P, Diener HC, et al. Therapie des Kopfschmerzes bei Medikamentenübergebrauch. Nervenheilkunde. 2013;32:135–44.
Compliance with Ethics Guidelines
ᅟ
Conflict of Interest
Stefan Evers is a section editor for Current Pain and Headache Reports.
Human and Animal Rights and Informed Consent
This article does not contain any studies with human or animal subjects performed by any of the authors.
Author information
Authors and Affiliations
Corresponding author
Additional information
This article is part of the Topical Collection on Childhood and Adolescent Headache
Rights and permissions
About this article
Cite this article
Evers, S. The Efficacy of Triptans in Childhood and Adolescence Migraine. Curr Pain Headache Rep 17, 342 (2013). https://doi.org/10.1007/s11916-013-0342-y
Published:
DOI: https://doi.org/10.1007/s11916-013-0342-y