Treatment Of Migraine In Children Research Articles

Treatment of migraine in children and adolescents. The state of the art

IntroductionHeadaches and migraine are common in the pediatric population, being one of the most frequent symptoms reported in practice. Additionally, it is a considerably disabling condition, which brings significant burden and impairs several aspects of a child or adolescent's life, such as mental and physical health, executive functioning, school performance. Children and adolescents with migraine have higher risk of psychiatric comorbidities and psychosocial adjustment difficulties, which, in turn, compromise even more patient's well-functioning.ObjectiveThe present article provides the clinician with a straightforward and evidence-based approach to migraine treatment in this age group.CommentTreatment of migraine in children and adolescents requires a systematic and thorough approach. Clinicians should keep in mind the important burden migraine brings to a child's life, thus investigate, and properly manage comorbidities presented. Patient and parents' education is a meaningful part of the treatment. Moreover, non-pharmacological treatments, such as healthy lifestyle habits, behavioral interventions may also play beneficial roles. When preventive treatment is indicated, it should be tailored considering drug's profile of effectiveness and safety, as well as patient's comorbidities. Lack of evidence in this context must not translate in lack of action by the clinician, since there may be a relevant burden associated. Therefore, reasoning for the perspicacious clinician is of fundamental importance and may influence positively the outcomes.

Beyond the Guidelines: A Narrative Review of Treatments on the Horizon for Migraine in Children and Adolescents.

Migraine is common in children and adolescents and can cause significant disability. There are relatively limited evidence-based treatment options available, especially when compared to treatment of migraine in adults. The Pediatric Research Equity Act requires the study of a new drug or biologic in pediatric populations. As such it is mandatory that the newest migraine treatment options available for adults be evaluated in children and adolescents. It will take years before results from clinical trials in pediatric patients become available. In the meantime, there is eagerness among clinicians to seek out the existing evidence that may help provide clarity on utilization of the newer migraine therapies in children and adolescents as many of the currently available, guideline-recommended treatments do not provide benefit for all patients. In this narrative review, literature regarding onabotulinumtoxinA, neuromodulatory devices, calcitonin gene-related peptide (CGRP) monoclonal antibodies, 5-hydroxytryptamine (1F) agonists (i.e. ditans), and CGRP small molecule receptor antagonists (i.e. gepants) for treatment of migraine in children and adolescents will be summarized.

Real Life Data on OnabotulinumtoxinA for Treatment of Chronic Migraine in Pediatric Age

The use of OnabotulinumtoxinA (OBT-A) for the treatment of chronic migraine (CM) in adults represents a therapy with the greatest efficacy and safety data. However, we have little evidence on the use of OBT-A in children or adolescents. The present study aims to describe the experience with OBT-A in the treatment of CM in adolescents in an Italian third-level headache center. The analysis included all patients under the age of 18 treated with OBT-A for CM at the Bambino Gesù Children's Hospital. All patients received OBT-A following the PREEMPT protocol. Subjects were classified as good responders if a greater than 50% reduction in the monthly frequency of attacks was observed, partial responders if the reduction was between 30 and 50%, and non-responders if it was <30%. The treated population consisted of 37 females and 9 males with a mean age of 14.7 years. Before starting OBT-A, 58.7% of the subjects had attempted prophylactic therapy with other drugs. From OBT-A initiation to the last clinical observation, the mean duration of follow-up was 17.6 ± 13.7 SD (range: 1-48) months. The number of OBT-A injections were 3.4 ± 3 SD. Sixty eight percent of the subjects responded to treatment within the first three administrations of OBT-A. Proceeding with the number of administrations, a progressive improvement in frequency was further observed. The use of OBT-A in pediatric age can have benefits in terms of reduction in the frequency and intensity of headache episodes. Furthermore, treatment with OBT-A has an excellent safety profile. These data support the use of OBT-A in the treatment of childhood migraine.

Comparing Pregabalin and Sodium Valproate in Pediatric Migraine Prophylaxis: A Randomized Clinical Trial.

Migraine is a common disorder in children, and its prophylaxis with minimal side effects is momentous. This study aimed to compare the efficacy of Pregabalin and Sodium Valproate in preventing migraine attacks. Sixty-four children (aged 6-18) with migraines were recruited, as defined by Internation Headache Criteria (ICHD-III). They were randomly assigned to two groups: Sodium Valproate (n=32) and Pregabalin (n=32). The minimum dosage of drugs was prescribed in both groups. The patients were followed for four months. The parameters such as frequency, intensity, duration of migraine attacks, and the number of painkillers that the patients used monthly were recorded. The Spence Children's anxiety scale was also used to evaluate medications' effect on patients' anxiety levels. Two medications were equally effective in reducing the intensity and duration of attacks. Additionally, their effect on reducing the anxiety level of patients was equal. There was a significant difference between the effect of drugs on the frequency of migraine attacks at the end of the first and fourth months and the number of painkillers used at the end of the fourth month. The frequency of attacks was decreased by more than 50% in twenty-eight patients (90%) of Pregabalin recipients and twenty-one patients (84%) of Sodium Valproate recipients. Considering the better effect of Pregabalin in the reduction of frequency of migraine attacks and pain-reducing medications consumption, Pregabalin could be a proper substitute for Sodium Valproate for prophylactic migraine treatment in children.

MELATONIN: ROLE IN THE PROPHYLAXIS OF MIGRAINE

Melatonin and migraine have been linked in most ways, from mechanisms to treatment. Migraine is one of the common neurological diseases and it is characterized by throbbing unilateral headache attacks. Migraine is an issue for both individuals and society. Migraine can lead to reduced work productivity and a flawed family and social life. It has been suggested that melatonin plays a key therapeutic role in treating migraines and several other types of headaches. Early and exact diagnosis is essential in enhancing treatment and in preventing progression. This review aimed to evaluate the available evidence related to the efficacy and safety of melatonin in the prophylaxis and prevention of migraine. Research in regard the administration of melatonin found it safe in migraine patients, with few or no side effects. This review concluded that Melatonin can be considered a safe integrative prophylactic treatment for children, adults and menstrual-related migraines, thus improving outcomes related to patient’s quality of life and patient-centered care. However, further studies and evaluation is required to confirm its effects.This review aimed to evaluate the available evidence related to the efficacy and safety of melatonin in migraine prophylaxis. Melatonin and migraine have been linked in a majority of ways, from mechanisms to treatment. Melatonin is an endogenous hormone and is secreted by the pineal gland. It plays an important role in regulating circadian rhythm and the sleep-wake cycle. It has been proposed for migraine prevention due to its anti-inflammatory effects against calcitonin gene-related peptides and other pro-inflammatory mediators in vitro, and its pro-regulatory effect on the circadian rhythm. Also, low melatonin levels have been reported in serum and urine due to hypothalamic dysfunction in patients with migraine. Hence, in this article, we review those papers describing the results of the administration of melatonin in humans for therapeutic purposes in treating migraines.This narrative literature review was based on studies on Melatonin's effectiveness, safety and tolerability for the prophylactic and preventive treatment of migraine in children and adolescents and menstruating women. The literature search was conducted using the Google Scholar and PubMed database and included articles published up to December 2021, utilizing the keywords: “melatonin”, “migraine”, “melatonin and migraine”, and “prophylaxis of migraine”. Observational studies, randomized controlled trials (RCTs), case reports and systematic reviews were included. The articles focusing on the latest medication for preventing migraines were also reviewed.

Migraine in children and adolescents: modern principles of diagnostics and treatment

Migraine is a nervous system disorder that affects 7.7% of children and can debut before the age of 3 years. As they get older, the incidence of migraine increases, and among adolescents, its prevalence reaches 15%. The disease can significantly reduce the child's daily activity, school performance. Migraine is the most common cause of headache in children and adolescents, but it is not always diagnosed; it is not uncommon for patients with migraine to be misdiagnosed and given ineffective treatment. An effective approach to the diagnosis of migraine in children is presented, diagnostic criteria for migraine according to the 3rd edition of International Classification of Headache Disorders are described. Special disorders in childhood are described – episodic syndromes in children associated with migraine. Migraine treatment in children includes four main approaches: 1) lifestyle recommendations; 2) migraine attack treatment; 3) nonpharmacological treatment; 4) migraine preventive pharmacotherapy. All of the listed approaches for the treatment of migraine in childhood are discussed in detail.

Are 5-HT1 receptor agonists (“triptans”) more effective than ibuprofen in the treatment of migraine in children and adolescents?

Are 5-HT1 receptor agonists (“triptans”) more effective than ibuprofen in the treatment of migraine in children and adolescents?

Melatonin for Acute Treatment of Migraine in Children and Adolescents: A Pilot Randomized Trial.

To determine what dose of melatonin is most effective for treating migraine acutely in children and adolescents. Acute migraine medications may not work for all patients and may cause side effects. Melatonin is effective for migraine prevention in adults and has been used acutely for procedural pain in children. Our goal was to determine whether a "high" or "low" dose of melatonin is more effective for treating migraine acutely in youth. In this pilot, randomized, open-label, single-center, dose-finding trial, children and adolescents aged 4-17years with episodic migraine were randomized to "high-dose" or "low-dose" dose melatonin (<40kg: 4mg vs. 1mg; ≥40kg: 8mg vs. 2mg). The primary outcome measure was change in mean pain score between time 0 and 2hours. Secondary outcomes included 2-hour pain-relief and pain-freedom rates. Eighty-four participants (n=42 per group) were enrolled in this study. Mean (SD) participant age was 11.8 (3.5) years and 55% (46/84) were female. Mean (SD) headache days/month was 5.6 (3.8). Sixty-six (79%) participants provided outcome data and were included in the analyses, n=24 in the high-dose group and n=22 in the low-dose group. The drop-out rate was 43% (18/42) in the high-dose group vs. 48% (20/42) in the low-dose group. Mean (SD) change in pain intensity at 2 hours was -2.7 (2.1) cm in the high-dose group vs. -2.3 (2.1) cm in the low-dose group (p=.581), a difference of 0.4cm (95% CI: -1.17 to 1.92). Two-hour pain-freedom rate was 41% (7/17) vs. 27% (4/15) in the high-dose vs. low-dose groups (p=.415), and 2-hour pain-relief rate was 94% (16/17) vs. 80% (12/15), (p=.482). There were no serious adverse events. Napping occurred in the majority (67% (14/21) high dose vs. 47% (9/19) low dose). Higher mg/kg dose of melatonin and napping were each independently associated with greater headache benefit. As an acute treatment for pediatric migraine,both low and high doses of melatonin were associated with pain reduction; however, study drop-out was high. Higher dose and napping after treatment predicted greater benefit.

P29 The preventative management of migraine headaches in paediatrics

AimTo determine the optimal preventative treatment option for paediatric migraineDesignA retrospective method. A review of 100 paediatric patients who attended outpatient clinics and their clinical outcomes evaluated at day 0, and at their next outpatient appointment (which is approximately 3 months after their first review). Their treatment was analysed to determine if they have remained on their migraine prophylaxis or changed to a different option.SettingChildren outpatient setting in a District General Hospital.Participants100 paediatric patients aged below 18 years of age.InterventionPatients aged below 18 years of age who have a documented diagnosis of migraine. This excluded abdominal migraine.Main Outcome MeasuresTo identify: which classes of drugs are being used for migraine prophylaxis, if there is a drug being used in preference to other drugs, how many preventative treatment options are tried before a preventative treatment is successful, if appropriate dosing regimens are being used for preventative treatment options, the common side effects (if any) of the drugs used in the management of migraine prophylaxis and if a different class of drug is being used for children under 12 years of age and over 12 years of age.Main ResultsPropranolol, topiramate, pizotifen, amitriptyline and gabapentin were medication used as initial treatment for paediatric migraine prophylaxis. Pizotifen was the most commonly used medication (n=71) and had the overall highest positive response rate of 76%. Topiramate, pizotifen and amitriptyline were noted to have caused side effects and prevent the subjects from continuing that course of prophylactic treatment. Age is a clinical factor which can influence the decision to start therapy. With a child’s advancing age, the features of childhood migraine change and therefore different medication may respond to the changing condition. It is evident from this research, pizotifen is used for children under the age of 12 years. However the true reason behind this is unknown. This could be due to the medication licensing or the side effect profile. Further trials are needed to review the demanding consideration on migraine in children of different ages. The BNF-C gives dosing advice on three preventative treatments; pizotifen, topiramate and propranolol. There was overall good compliance with dosing as per the BNFC; 91% in the pizotifen group, 100% in the topiramate group and 82% compliance in the propranolol group. In the BNF-C, for amitriptyline and gabapentin there is no dosing advice for migraine prophylaxis. Therefore, there was no dosing regimens to compare to and achieved 0% compliance with the BNF-C.ConclusionThis research has found pizotifen to be first line treatment for the prevention of migraines. Numerous medication have been identified as potentially preventing migraine but these have either not progressed to fruition or failed to achieve the expected outcomes. Further medication studies are needed to examine their effectiveness for preventing paediatric migraine.ReferencesBarnes N. ( 2019) ‘Migraine Headache in Children’, British Medical Journal. Available at: https://bestpractice.bmj.com/topics/en-gb/678/evidence (Accessed February 2019)Bille BO. ( 1997) ‘A 40-year follow-up of children with migraine’. Cephalalgia 1997;17:488–91. Available at: https://www.ncbi.nlm.nih.gov/pubmed/9209767 (Accessed January 2019)Brandes JL Saper JR, Diamond M, et al. (2004) ‘Topiramate for migraine prevention: A randomized controlled trial’. JAMA. 2004;291:965–973. Available at: https://www.ncbi.nlm.nih.gov/pubmed/14982912 (Accessed January 2019)Forsythe WI, Gillies D, Sills MA. ( 1984) ‘Propranolol in the treatment of childhood migraine’, Developmental Medicine and Child Neurology Journal, 26: 737–41.

Correction to: Intravenous Migraine Treatment in Children and Adolescents.

The original publication of this article unfortunately contained the incorrect version of the manuscript. The original article has been corrected.

Guidelines of the International Headache Society for controlled trials of preventive treatment of migraine attacks in episodic migraine in adults

Clinical trials are a key component of the evidence base for the treatment of headache disorders. In 1991, the International Headache Society Clinical Trials Standing Committee developed and published the first edition of the Guidelines for Controlled Trials of Drugs in Migraine. Advances in drugs, devices, and biologicals, as well as novel trial designs, have prompted several updates over the nearly 30 years since, including most recently the Guidelines for controlled trials of preventive treatment of chronic migraine (2018), the Guidelines for controlled trials of acute treatment of migraine attacks in adults (2019), and Guidelines for controlled trials of preventive treatment of migraine in children and adolescents (2019). The present update incorporates findings from new research and is intended to optimize the design of controlled trials of preventive pharmacological treatment of episodic migraine in adults. A guideline for clinical trials with devices will be published separately.

Intravenous Migraine Treatment in Children and Adolescents.

Pediatric migraine is a common, chronic, and disabling neurological disorder in children and adolescents. Outpatient management is not always effective, and intravenous migraine management may be necessary for headache treatment in the pediatric emergency department. Most current treatment is based on retrospective evidence and there is a lack of well-designed randomized double-blinded controlled pediatric studies. Intravenous drug treatment agents including intravenous fluids, prochlorperazine, diphenhydramine, metoclopramide, dexamethasone, magnesium, valproate and propofol, and dihydroergotamine are reviewed in this paper. Nineteen studies were reviewed including one prospective randomized double-blind; one single-blinded randomized; one prospective; and one open-label, randomized clinical trial. Most studies were retrospective and the quality of the studies was limited. No definite conclusions can be drawn from the studies, but appropriate prospective trials between major pediatric headache institutions will move pediatric intravenous migraine management forward.

Acute Treatment of Pediatric Migraine: A Review of the Updated Guidelines.

The purpose of the Research to Practice column is to review and critique current research articles that directly affect the practice of the advanced practice nurse (APN) in the emergency department. This review examines the findings of M. from their article, "Practice guideline update summary: Acute treatment of migraine in children and adolescents: Report of the Guideline Development, Dissemination, and Implementation Subcommittee of the American Academy of Neurology and the American Headache Society." The authors completed an extensive literature review and created eight recommendations for the acute treatment of pediatric migraine focusing on medication selection, dosing, patient education, and patient counseling. By applying the evidence-based guidelines presented in this study, the urgent care or emergency department APN can confidently recognize and treat acute migraine symptoms and reduce patient risks from unnecessary testing and overuse of acute migraine medications.

Evidence Regarding Medication Overuse Headache in Children and Adolescents: Protocol for a Systematic Review.

This proposed systematic review will identify the existing evidence on medication-overuse headache in children and adolescents. A number of medications have been shown to be effective for acute treatment of migraine in children and adolescents. However, patients may find they need to use their acute medications more frequently when migraine frequency is high. This has led to concern about their potential to develop medication-overuse headache. We will search PubMed, Embase, Web of Science, PsycINFO, and Cochrane databases from their inception to present time. We will also search conference proceedings of the last 4 scientific meetings of relevant societies and scan the reference lists of studies identified through the search. Study designs will include case series, cross-sectional, cohort, case-control, and interventional studies. Participants will include children and adolescents under 18years of age with primary headache disorders. We aim to determine whether frequency of acute medication use is associated with headache frequency in children and adolescents. Outcomes of interest include: (1) headache frequency; (2) change in headache frequency, with time and in relationship to use of acute medications; and (3) headache-related disability. We will also review data addressing treatment/management of medication overuse or medication-overuse headache in children and adolescents. Relevant comparators will be withdrawal vs reduction of acute medication, initiation of preventive therapy vs no initiation with or without withdrawal of acute medication, and initiation of preventive therapy early vs late. Outcomes of interest include (1) days of acute medication use; (2) headache frequency; (3) change in headache frequency; and (4) headache-related disability. After screening for inclusion, 2 team members will independently review and extract relevant data, and any discrepancies will be resolved through discussion and arbitration. We will assess risk of bias using appropriate tools (Cochrane Risk of Bias for randomized controlled trials (RCT) and Newcastle-Ottawa Score for observational studies). Data will be summarized descriptively in text and tables. This systematic review will provide an overview of the available evidence on medication-overuse headache in children and adolescents. Findings from this review will aid clinicians by clarifying for them the current state of the evidence base, and will inform design of future research on this topic.

Practice guideline update summary: Acute treatment of migraine in children and adolescents: Report of the Guideline Development, Dissemination, and Implementation Subcommittee of the American Academy of Neurology and the American Headache Society.

In the Special Article “Practice guideline update summary: Acute treatment of migraine in children and adolescents: Report of the Guideline Development, Dissemination, and Implementation Subcommittee of the American Academy of Neurology and the American Headache Society” by Oskoui et al.,1 the following disclaimer/publication statement should have been included: “These guidelines were jointly developed by the American Academy of Neurology Institute and American Headache Society. This article was peer reviewed and first published by Neurology , and subsequently published in Headache .” The publisher regrets the error.

Acute Treatment of Migraine in Children and Adolescents.

The management of headaches with juvenile onset presents several problems, related not only to appropriate drug selection but also to the specific features distinguishing headache disorders in children and adolescents: a child is not a "little adult". Many age-related factors influence the clinical expression of headache and these should be taken into account not only in the treatment, but also in the diagnosis, of juvenile headache. Few randomised placebo-controlled clinical trials of acute or preventive drugs have been conducted in paediatric headache patients, and those that have show a high placebo response rate in children (e.g. up to 55% for prophylactic drugs and up to 69% for symptomatic ones). The available data on symptomatic drugs are presented and discussed, focusing, in particular, on mechanisms of action, evidence of efficacy, and tolerability.

Practice guideline update summary: Acute treatment of migraine in children and adolescents: Report of the Guideline Development, Dissemination, and Implementation Subcommittee of the American Academy of Neurology and the American Headache Society.

To provide evidence-based recommendations for the acute symptomatic treatment of children and adolescents with migraine. We performed a systematic review of the literature and rated risk of bias of included studies according to the American Academy of Neurology classification of evidence criteria. A multidisciplinary panel developed practice recommendations, integrating findings from the systematic review and following an Institute of Medicine-compliant process to ensure transparency and patient engagement. Recommendations were supported by structured rationales, integrating evidence from the systematic review, related evidence, principles of care, and inferences from evidence. There is evidence to support the efficacy of the use of ibuprofen, acetaminophen (in children and adolescents), and triptans (mainly in adolescents) for the relief of migraine pain, although confidence in the evidence varies between agents. There is high confidence that adolescents receiving oral sumatriptan/naproxen and zolmitriptan nasal spray are more likely to be headache free at 2 hours than those receiving placebo. No acute treatments were effective for migraine-related nausea or vomiting; some triptans were effective for migraine-related phonophobia and photophobia. Recommendations for the treatment of acute migraine in children and adolescents focus on the importance of early treatment, choosing the route of administration best suited to the characteristics of the individual migraine attack, and providing counselling on lifestyle factors that can exacerbate migraine, including trigger avoidance and medication overuse.

Acupuncture in Adult and Pediatric Headache: A Narrative Review.

Headaches in children and adolescents remain a very common problem with migraine being the most common headache disorder to present to medical attention. The approach to the treatment of migraine in children has consisted of treatment with acute and preventive medications, combined with lifestyle modification and behavioral interventions, such as cognitive behavioral therapy. With increasing frequency, complementary and alternative medicine (CAM) approaches, including acupuncture, are often recommended in the pediatric population to address significant disability with limited evidence-based treatment options. In this article, the authors conduct a review of acupuncture in pediatric headache, including neurobiological mechanisms, adult headache studies, pediatric headache studies, safety, and use of acupuncture in other conditions in children. This article aims to summarize the currently available evidence with which to recommend acupuncture in children for the adjunctive treatment of headache. Acupuncture appears to be safe and effective for the treatment of migraine in children.

Practice guideline update summary: Acute treatment of migraine in children and adolescents: Report of the Guideline Development, Dissemination, and Implementation Subcommittee of the American Academy of Neurology and the American Headache Society.

To provide evidence-based recommendations for the acute symptomatic treatment of children and adolescents with migraine. We performed a systematic review of the literature and rated risk of bias of included studies according to the American Academy of Neurology classification of evidence criteria. A multidisciplinary panel developed practice recommendations, integrating findings from the systematic review and following an Institute of Medicine-compliant process to ensure transparency and patient engagement. Recommendations were supported by structured rationales, integrating evidence from the systematic review, related evidence, principles of care, and inferences from evidence. There is evidence to support the efficacy of the use of ibuprofen, acetaminophen (in children and adolescents), and triptans (mainly in adolescents) for the relief of migraine pain, although confidence in the evidence varies between agents. There is high confidence that adolescents receiving oral sumatriptan/naproxen and zolmitriptan nasal spray are more likely to be headache-free at 2 hours than those receiving placebo. No acute treatments were effective for migraine-related nausea or vomiting; some triptans were effective for migraine-related phonophobia and photophobia. Recommendations for the treatment of acute migraine in children and adolescents focus on the importance of early treatment, choosing the route of administration best suited to the characteristics of the individual migraine attack, and providing counseling on lifestyle factors that can exacerbate migraine, including trigger avoidance and medication overuse.

Comparison between flunarizine and levetiracetam in paediatric migraine prophylaxis

Background: Migraine hampers child's life through school absence, limitation of home and social activities. The goal of prophylactic (preventive) therapy is to reduce headache frequency, headache days, and headache severity with minimum side effects.&#x0D; Objective: To evaluate the efficacy and tolerability of levetiracetam compared to flunarizine as prophylactic treatment of Migraine in children. Methods: This prospective study was carried out in the outpatient department of a tertiary care hospital in Bangladesh. A total of 105 children aged 6-15 years, diagnosed as migraine without aura, were enrolled. Patients were treated with flunarizine or levetiracetam for three months. Headache disabilities were evaluated at baseline and at the end of three months.&#x0D; Results: In flunarizine group, 54 children and in levetiracetam group, 51 children were enrolled. Among them thirty nine children in flunarizine group and 36 children in levetiracetam group completed the study. Headache frequency, headache days, VAS (Visual Analogue Scale) score and PedMIDAS (Paediatric Migraine Disability Assessment Score) score were evaluated at baseline and during the follow up. After three months, headache frequency, headache days, pain severity (Visual Analogue Scale score) reduced significantly compared to baseline (p&lt;0.05). PedMIDAS score was also reduced from 60.35(±16.36) to 30.13(±14.28) in flunarizine group and from 64.25(±19.63) to 25.91(±18.6) in levetiracetam group (p&lt;0.05). Some minor side effects were also reported by both groups, but were well tolerated by the patients and need not withdrawal of medication.&#x0D; Conclusion: Levetiracetam is as effective as flunarizine in paediatric Migraine Prophylaxis.&#x0D; Bang Med J (Khulna) 2018; 51 : 35-39