This prospective, pediatric headache telemedicine study shows that telemedicine is convenient, perceived to be cost-effective, and patient-centered. Providing the option of telemedicine for routine pediatric headache follow-up visits results in high patient and family satisfaction.

Comorbidities in infants with OSA differ from those of older children. Based upon the comorbidities identified in our study population, it appears that appropriate management of infants with OSA requires a multidisciplinary approach involving genetics, gastroenterology, pulmonology, otolaryngology, neurology, and general pediatrics.

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Common thought is that increased frequency and severity of headache may reflect secondary pathology; however, headache phenotype may not be fully developed and can evolve in adolescence or adulthood. Headache location, particularly occipital headache alone, does not necessarily signify secondary intracranial pathology. Certain warning signs warrant neuroimaging, but others only warrant imaging in certain clinical contexts. Brain MRI is the neuroimaging modality of choice, though there is a high rate of incidental findings and often does not change headache management. A stepwise approach is essential to avoid missing secondary headaches. There are several differences between adults and children in clinical manifestations of headache. Evaluation and diagnosis of pediatric headache starts with a thorough headache and medical history, family and social history, and identification of risk factors. A thorough physical and neurologic exam is important, with close attention to features that could suggest secondary headache pathology. Neuroimaging and other testing should only be performed if there is concern for secondary headache.

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sTMS appears to be a feasible, well-tolerated, and acceptable nonpharmacologic preventive treatment for migraine in adolescents. In designing future trials of sTMS for migraine prevention in adolescents, streamlined treatment administration will be essential to minimize drop-out. Efficacy needs to be assessed in a larger trial.

Randomized trials are needed to identify safe and effective migraine preventive treatments for children. Conventional trials typically require frequent in-person study visits. 1 Many families decline study participation, citing time and distance. 2 Home-based trials are a novel, participant-centered design innovation wherein most or all study procedures are completed remotely using technology. Melatonin is safe and effective for migraine prevention in adults. 3 In this pilot study, we assessed the feasibility of a homebased trial of melatonin for adolescent migraine prevention. Methods | We conducted a randomized, double-blind, placebocontrolled pilot study of melatonin, 3 mg (Rugby Laboratories), vs placebo for migraine prevention in children aged 12 to 17 years. Participants were recruited via our clinic, flyers, social media, print advertisements, and parent letters (Table 1). Screening occurred on our study website; eligible participants were invited for a 1-time study center enrollment visit. Diagnosis of migraine by International Classification of Headache Disorders, 3rd edition (beta version) criteria 4 was confirmed by a pediatric headache neurologist. Remaining study procedures were conducted from home. The institutional review board of the University of California, San Francisco approved this study (clinicaltrials.gov identifier: NCT02344316). Parents provided written informed consent and adolescents provided assent. Participants received a nightly text message on their smartphone that linked to a secure web-based electronic headache diary. Study staff monitored diary compliance and provided reminders. After a 28-day baseline, those with 80% or greater diary compliance and the requisite number of headaches were randomized to melatonin or placebo for 12 weeks. Study medication was shipped to homes. Participants recorded sleep using Fitbits (Fitbit Inc). Sleep data synced to participants' smartphones or computers and automatically transferred to the study database via application program interface calls. Adverse events were assessed via telephone twice monthly. The enrollment goal was 30 participants. The aims of this study were to (1) determine the success vs cost of various recruitment strategies, (2) demonstrate enrollment feasibility, (3) estimate study completion rate, (4) estimate variance in headache outcomes using home-trial methodology, and (5) assess adverse events. Mann-Whitney, χ 2 , and Fisher exact tests as well as multivariable linear regression were used.

Objective To determine what dose of melatonin is most effective for treating migraine acutely in children and adolescents. Background 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. Methods In this pilot, randomized, open‐label, single‐center, dose‐finding trial, children and adolescents aged 4‐17 years with episodic migraine were randomized to “high‐dose” or “low‐dose” dose melatonin (<40 kg: 4 mg vs. 1 mg; ≥40 kg: 8 mg vs. 2 mg). The primary outcome measure was change in mean pain score between time 0 and 2 hours. Secondary outcomes included 2‐hour pain‐relief and pain‐freedom rates. Results 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 0.4 cm (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. Conclusions 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.