Migraine is a common and disabling long-term condition in childhood. It is suggested that a liberal interpretation of the International Headache Society diagnostic criteria should enable a wider number of children with migraine to receive appropriate medicines. As for many medicines for children, the evidence base for effectiveness is modest. This review contrasts current authoritative recommendations in the UK with the evidence base and offers a rationale for the use of a number of off-label and unlicensed preparations, while we wait for the evidence base to be developed further. A hierarchy of treatment options is presented.

DIAGNOSIS OF MIGRAINE

Even though there are fairly rigid criteria for the diagnosis of migraine, few patients have read them before presenting themselves to outpatients or to the emergency room.¹ In clinical practice a more liberal interpretation of symptomatology is likely to be helpful and increases the number of patients who might benefit from medical intervention. Cluster analysis of headache symptoms in children has identified three groups of symptoms clusters—none of which matched the diagnostic classification of the International Headache Society.² The first group typically had unilateral pulsating headaches with nausea and vomiting, phonophobia and photophobia. The second cluster had typically bilateral headaches, described as from dull to stabbing and commonly with nausea, vomiting, blurred vision, diplopia and flashing lights. The third and largest group had bilateral headaches described as pulsating or pressing with nausea and vomiting but few other symptoms. It is therefore not always useful to be constrained by traditional classifications which have been developed from practice in adults. However, even where such criteria are strictly applied child populations have a high prevalence of migraine (10.6% in one UK sample³) and are likely to seek health services for diagnosis, reassurance and treatment.

WHICH CLASSES OF DRUGS CAN BE USED FOR TREATMENT?

A whole range of physiological and pathological processes have been …