BNF for Children 2011-2012

214 4.7.4 Antimigraine drugs BNFC 2011–20124 Central nervous systemangina pectoris, myocardial infarction; with nasalspray, taste disturbance, and epistaxisLicensed use not licensed for use in childrenIndication and doseTreatment of acute migraine. By mouthChild 12–18 years 2.5 mg, repeated after not lessthan 2 hours if migraine recurs (if response unsatisfactoryafter 3 attacks consider increasing doseto 5 mg or switching to alternative treatment);max. 10 mg in 24 hours. IntranasallyChild 12–18 years 5 mg (1 spray) into 1 nostril,repeated after not less than 2 hours if migrainerecurs; max. 10 mg in 24 hoursTreatment of acute cluster headache. IntranasallyChild 12–18 years 5 mg (1 spray) into 1 nostril,repeated after not less than 2 hours if headacherecurs; max. 10 mg in 24 hoursZomig c (AstraZeneca) ATablets, f/c, yellow, zolmitriptan 2.5 mg, net price 6-tab pack = £18.00, 12-tab pack = £36.00Orodispersible tablets (Zomig Rapimelt c ), zolmitriptan2.5 mg, net price 6-tab pack = £17.90; 5 mg, 6-tab pack = £22.80. Counselling, administrationCounselling Zomig Rapimelt c should be placed on thetongue, allowed to disperse and swallowedExcipients include aspartame equivalent to phenylalanine 2.81 mg/tablet (section 9.4.1)Nasal spray, zolmitriptan 5 mg/0.1-mL unit-dosespray device, net price 6 unit-dose sprays = £36.50AntiemeticsAntiemetics (section 4.6), including metoclopramide,domperidone, phenothiazines, and antihistamines,relieve the nausea associated with migraine attacks.Antiemetics may be given by intramuscular injectionor rectally if vomiting is a problem. Metoclopramide anddomperidone have the added advantage of promotinggastric emptying and normal peristalsis; a single doseshould be given at the onset of symptoms (important:for warnings relating to extrapyramidal effects of metoclopramidesee p. 192 and p. 196).4.7.4.2 Prophylaxis of migraineWhere migraine attacks are frequent, possible provokingfactors such as stress should be sought; combinedoral contraceptives may also provoke migraine. Preventivetreatment should be considered if migraine attacksinterfere with school and social life, particularly forchildren who:. suffer at least two attacks a month;. suffer an increasing frequency of headaches;. suffer significant disability despite suitable treatmentfor migraine attacks;. cannot take suitable treatment for migraine attacks.In children it is often possible to stop prophylaxis after aperiod of treatment.Propranolol (section 2.4) may be effective in preventingmigraine in children but it is contra-indicated in thosewith asthma. Side-effects such as depression and posturalhypotension can further limit its use.Pizotifen, an antihistamine and serotonin antagonist,taken at night or twice daily, may also be used but itsefficacy in children has not been clearly established.Common side-effects include drowsiness and weightgain.Topiramate (section 4.8.1) is licensed for migraineprophylaxis.PIZOTIFENCautions urinary retention; susceptibility to angleclosureglaucoma; history of epilepsy; interactions:Appendix 1 (pizotifen)Skilled tasks Drowsiness may affect performance of skilledtasks (e.g. driving); effects of alcohol enhancedRenal impairment use with cautionPregnancy avoid unless potential benefit outweighsriskBreast-feeding amount probably too small to beharmful but manufacturer advises avoidSide-effects dry mouth, nausea, dizziness, drowsiness,increased appetite, weight gain; less commonlyconstipation; rarely anxiety, aggression, insomnia,paraesthesia, hallucination, depression, arthralgia,myalgia; very rarely seizuresLicensed use 1.5-mg tablets not licensed for use inchildrenIndication and doseProphylaxis of migraine. By mouthChild 5–10 years initially 500 micrograms at nightincreased according to response up to 500 micrograms3 times daily; max. single dose at night1 mg; max. 1.5 mg in 24 hoursChild 10–12 years initially 1 mg at nightincreased according to response up to 500 micrograms3 times daily; max. single dose at night1 mg; max. 1.5 mg in 24 hoursChild 12–18 years initially 1.5 mg at nightincreased according to response to 1.5 mg 3 timesdaily; max. single dose 3 mg; max. 4.5 mg in 24hoursPizotifen (Non-proprietary) ATablets, pizotifen (as hydrogen malate), 500 micrograms,net price 28-tab pack = £1.28; 1.5 mg, 28-tabpack = £2.17. Label: 2Sanomigran c (Novartis) ATablets, both ivory-yellow, s/c, pizotifen (as hydrogenmalate), 500 micrograms, net price 60-tab pack =£2.06; 1.5 mg, 28-tab pack = £3.42. Label: 2Elixir, pizotifen (as hydrogen malate) 250 micrograms/5mL, net price 300 mL = £3.61. Label: 24.7.4.3 Cluster headache and thetrigeminal autonomiccephalalgiasCluster headache rarely responds to standard analgesics.Sumatriptan given by subcutaneous injectionis the drug of choice for the treatment of cluster head-