Practice guideline update summary: Pharmacologic treatment for pediatric migraine prevention

Abstract

Objective To provide updated evidence‐based recommendations for migraine prevention using pharmacologic treatment with or without cognitive behavioral therapy in the pediatric population. Methods The authors systematically reviewed literature from January 2003 to August 2017 and developed practice recommendations using the American Academy of Neurology 2011 process, as amended. Results Fifteen class I‐III studies on migraine prevention in children in adolescents met inclusion criteria. There is insufficient evidence to determine if children and adolescents receiving divalproex, onabotulinumtoxinA, amitriptyline, nimodipine and flunarizine are more or less likely than those receiving placebo to have a reduction in headache frequency. Children with migraine receiving propranolol are possibly more likely than those receiving placebo to have an at least 50% reduction in headache frequency. Children and adolescents receiving topiramate and cinnarizine are probably more likely than those receiving placebo to have a decrease in headache frequency. Children with migraine receiving amitriptyline plus cognitive behavioral therapy are more likely than those receiving amitriptyline plus headache education to have a reduction in headache frequency. Recommendations The majority of randomized controlled trials studying the efficacy of preventive medications for pediatric migraine fail to demonstrate superiority to placebo. Recommendations for the prevention of migraine in children include counseling on lifestyle and behavioral factors that influence headache frequency, and assessment and management of comorbid disorders associated with headache persistence. Clinicians should engage in shared decision making with patients and caregivers regarding the use of preventive treatments for migraine, including discussion of the limitations in the evidence to support pharmacologic treatments.

Early clinical experience with a monoclonal antibody against the calcitonin gene-related peptide receptor in adolescents with migraine: A case series

“…Effective and well-tolerated migraine preventive therapies for children and adolescents are limited. 5 Increasing the evidence base with good quality studies to provide age-appropriate guidance on the efficacy and safety of CGRP monoclonal antibody is urgently needed to fulfill the unmet needs in this population of migraine patients.…”

“…The majority of randomised controlled studies on the agents used in adults fail to demonstrate superiority to placebo in paediatric patients with migraine. 5 Off-label prescribing for the treatment of migraine in children and adolescents, as well as undertreatment, are common, as many of the approved pharmacological agents have age restrictions. 6 More recent research has led to the development of monoclonal antibodies targeting either the CGRP molecule or receptor, opening up new vistas in migraine-specific treatment.…”

Association Between Peer Victimization, Gender Diversity, Mental Health, and Recurrent Headaches in Adolescents

“…The results of this study should compel future research into interventions for peer victimization and future work aimed at better understanding whether and how gender-diverse youth are at higher risk of headache disorders. Clinicians should not only screen children and adolescents with headache disorders for anxiety and depression as suggested in prior work 21,43 but also for peer victimization and suicidality, which may be independently associated with headache risk and possibly with worse headache-related outcomes such as higher headache frequency.…”

Depression and anxiety are not associated with migraine outcomes in children and adolescents

“…The cited rationale for these statements is that a systematic review of longitudinal studies found that children and adolescents with "negative emotional states" were more likely to experience persistence of recurrent headache, which was defined as headache at least once a month. 1,2 In this issue of the journal, Rizvi et al 3 bring these guideline statements into question. Their prospective longitudinal cohort study enrolled children and adolescents with migraine aged 8-18 years who were seen by a pediatric headache specialist at a children's hospital in Calgary.…”