A dilemma in pediatric migraine: Headache or school performance? – A comparison of topiramate and flunarizine

BACKGROUND: Migraine prophylaxis reduces pain severity and duration in pediatric patients, improving school and social adaptation. Topiramate (TPM) and flunarizine (FLN) are effective monotherapies for migraine prevention. This study compares their efficacy in pain management and impact on school and social life. METHODS: This two-group comparative study (2018-2023) included pediatric patients (aged 9-18 years) diagnosed with episodic or chronic migraine based on International Classification of Headache Disorders, 3rd edition (ICHD-3 beta) criteria. Patients were assessed for demographic characteristics, pain duration, pain frequency, pain intensity using the Visual Analogue Scale (VAS), Pediatric Migraine Disability Assessment Scale (PedMIDAS) scores, side effects, and treatment attitudes at baseline and after three months of TPM or FLN treatment. RESULTS: Among 226 patients, TPM showed a greater reduction in pain frequency than FLN (9.0 vs. 7.5; p = 0.007). The percentage reduction in monthly pain frequency was higher with TPM (83.5 % vs. 70.7 %; p = 0.022). Side effects were significantly lower in the FLN group. TPM caused weight loss, paresthesia, speech/memory impairment, and appetite reduction, while FLN caused weight gain (p < 0.001). TPM was more effective in reducing pain frequency (relative risk [RR] = 0.118; 95 % confidence interval [CI] -0.946 to -0.681; p = 0.011), pain duration (RR = 0.858, 95 % CI -2.640 to -1.350; p < 0.001), and pain intensity (RR = 0.729, 95 % CI -1.849 to -0.539; p < 0.001). However, FLN was superior in PedMIDAS scores, particularly in school attendance and participation (p < 0.001). No patients withdrew, but some were reluctant to use TPM due to concerns about stigmatization. Notably, substantial placebo effects have been observed in pediatric migraine trials, and the current evidence for the efficacy of preventive medications in this population remains limited. CONCLUSION: TPM and FLN are effective migraine treatments. TPM is superior for pain reduction, while FLN has fewer side effects and benefits school attendance and participation. Weight changes and stigma should be considered when prescribing TPM.