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Three Part Question

In [an adolescent with migrainous headaches ] does [oral or intranasal sumatriptan] reduce [headache intensity]?

Clinical Scenario

A 14-year-old boy attends your general clinic suffering from weekly headaches for the last 6 months. The description of the headaches are typical for migraine headaches, neurological examination is normal. There is a strong family history of migraines in the mother and a sister. He already has made adjustments to his lifestyle by avoiding trigger foods and a regular sleep pattern with limited improvement. He is reluctant to take regular prophylactic medication but his parents are concerned about the amount of analgesia he takes. As his mother uses sumatriptan with good effect she wants to know if this would be an option for him.

Search Strategy

Cochrane library and Pubmed
Cochrane library: Sumatriptan or Migraine or Headache
Pubmed: "Migraine (explode) or headache*" and *triptan, limit to therapy set to sensitive search,

Search Outcome

2 RCTs of nasal sumatriptan use in adolescents
1 RCT of oral sumatriptan
For results see table

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Ahonen et al, Finland 2004	83 children [8-17 yrs] IHS congruent migraine; single dose of SNS 10/20mg, and matching placebo administered at home during 2 attacks.	Double blind placebo controlled 2 way crossover trial.	Primary efficacy endpoint headache relief by 2 grades on a 5 grade face scale at 2 hrs.	At 1 hr headache relief SNS[n=42/83 51%] v placebo[n= 24/83 29%] NNT=5. At 2 hrs SNS[n=53/83 64%] v placebo [n=32/83 39%] NNT= 4	Bad taste after SNS commonest adverse effect in 29%[n=26/90] of attacks
Winner et al, 2000 Florida, USA	653 US 12-17 yr olds with IHS congruent migraine for 6/12; SNS 5 mg, 10 mg, 20 mg v placebo, single attack	Randomised, double blind, placebo controlled single attack study	Primary efficacy endpoint headache relief 2 hrs post dose SNS 20mg v placebo Adverse events, ECG changes, physical exam noted.	Headache relief 2 hrs post dose statistically significant for 20 mg SNS v placebo[63% v 53%.NNT=8]. Complete relief 2 hrs post dose SNS v placebo 36% v25% NNT=9	Taste disturbance most common adverse event. SNS 20 mg [26%] v placebo [2%] NNH :4
Hamalainen et al, Finland 1997	23 children 8.3 to 16.4 years old with typical migraine oral sumatriptan 25 mg	Randomized placebo controlled, double- blind, cross-over	50% decrease in pain intensity on visual analogue scale at 2 hours. Other outcome measure: pain intensity difference	7/23 (30%) on sumatriptan versus 5/23 (22%) on placebo achieved pain relief at 2 hours ARR 8% NNT 13 5/23 (22%) versus 2/23 (9%) achieved complete headache relief ARR 13% NNT 8	Small Study size Confidence interval for ARR cross zero Study quality not sufficient to prove efficacy

Comment(s)

Migraine is a common diagnosis for children presenting to a general paediatric clinic with headaches. Many children and their parents prefer treatment targeted at the onset of headaches rather than regular prophylaxis and are worried about overusing analgesia. In adults sumatriptan intranasal and orally has been shown to be effective for the treatment of single acute migraine attacks as measured by pain-free response or relief of headache at 2 hours compared to placebo (McCrory, Gawel).

Clinical Bottom Line

In adolescents with typical migraine nasal and oral sumatriptan is effective in relieving pain (NNT 4 – 9) compared to placebo. There are currently no trials directly comparing simple analgesia versus sumatriptan in adolescents.

References

1. Ahonen K. Hamalainen ML. Rantala H. Hoppu K. Nasal sumatriptan is effective in treatment of migraine attacks in children : A randomized trial. Neurology 2004:62(6): 883-7.
2. Winner P. Rothner AD. Saper J. Nett R. Asgharnejad M. Laurenza A. Austin R. Peykamian M. A randomised double- blind placebo controlled study of sumatriptan nasal spray in the treatment of acute migraine in adolescents. Pediatrics 2000:106(5):989-97.
3. Hamalainen, M L. Hoppu, K. Santavuori, P. Sumatriptan for migraine attacks in children: a randomized placebo-controlled study. Do children with migraine respond to oral sumatriptan differently from adults?. Neurology. 48(4):1100-3, 1997 Apr.
4. McCrory DC and Gray RN. Oral sumatriptan for acute migraine. The Cochrane Database of Systematic Reviews 2003, Issue 3. Art. No.: CD002915. DOI: 10.1002/14651858.CD002915.
5. Gawel MJ. Worthington I. Maggisano A. A systematic review of the use of triptans in acute migraine. Canadian Journal of Neurological Sciences. 28(1):30-41, 2001 Feb.