PedMIDAS: development of a questionnaire to assess disability of migraines in children

Divalproex extended-release in adolescent migraine prophylaxis: results of a randomized, double-blind, placebo-controlled study

OBJECTIVE

To evaluate the efficacy, tolerability, and safety of 3 different doses of divalproex sodium extended-release vs placebo in the prophylaxis of migraine headaches in adolescents.

BACKGROUND

Divalproex sodium has been approved for migraine prophylaxis in adults, and previous uncontrolled data suggest divalproex sodium may be effective in preventing migraine in children and adolescents with acceptable tolerability.

METHODS

This was a 12-week, phase 3, randomized, placebo-controlled, double-blind, parallel-group, multicenter study in approximately 300 adolescents aged 12 to 17 years with migraine headaches. At the end of the baseline phase, subjects still meeting study criteria were randomized in a 1:1:1:1 ratio to receive divalproex sodium extended-release 250 mg, 500 mg, or 1000 mg once daily, or placebo. The primary efficacy variable was reduction from baseline in 4-week migraine headache rate for each active treatment group vs placebo. Standard safety assessments were conducted and testosterone and sex hormone-binding globulin levels were collected for postmenarchal females.

RESULTS

There was no statistically significant treatment difference between any divalproex sodium extended-release dose group and placebo for the primary efficacy variable, reduction from baseline in 4-week migraine headache rate. There were no statistically significant differences in adverse events between any active treatment group and placebo. A notable dose-related decrease in platelets was observed, and individuals in all 4 treatment groups had increases in ammonia levels; treatment differences in other laboratory variables were generally small. Among postmenarchal female subjects who were not taking hormonal contraceptives or other steroids, there was no statistically significant change in testosterone levels, but a statistically significant dose-related increase in sex hormone-binding globulin was observed.

CONCLUSIONS

In the current study, divalproex sodium extended-release did not differentiate from placebo in the prophylactic treatment of migraine headaches but was generally well-tolerated in adolescents aged 12 to 17 years.

Headache disability among adolescents: a student population-based study

OBJECTIVE

To examine the extent and to identify the relevant predictors of headache disabilities in adolescents.

BACKGROUND

Headaches are common in adolescents but their impact and related factors have not been extensively studied in adolescent communities.

METHOD

We recruited and surveyed 3963 students aged 13-15 from 3 middle schools using self-administered questionnaires. The questionnaires were used to make 3 assessments: (1) headaches were diagnosed using a validated headache questionnaire; (2) headache disabilities were evaluated using the 6-question Pediatric Migraine Disability Assessment; (3) depression was measured using the Adolescent Depression Inventory.

RESULTS

The student response rate was 93%. In total, 484 students (12.2%) had migraines with or without auras, 444 (11.2%) had probable migraines, and 1092 (27.6%) had tension-type headaches. The students with migraine had the highest Pediatric Migraine Disability Assessment scores (10.7 +/- 20.0); whereas, the students with tension-type headaches had the lowest scores (2.0 +/- 4.4). Logistic regression analyses indicated that there were a number of independent predictors for moderate to severe headache-related disability (Pediatric Migraine Disability Assessment score > or =31), including a migraine or probable migraine diagnosis, a higher depression score, severe headache intensity, and frequent headaches.

CONCLUSIONS

The Pediatric Migraine Disability Assessment provides a simple tool to measure the impact of headaches in adolescents. Adolescents with migraine headaches suffered the greatest level of disability. Higher depression scores were associated with more severe headache-related disabilities in adolescents, independent of headache frequency and severity.

Impact of headache on young people in a school population

BACKGROUND

Headache is the most frequent neurological symptom and the most common manifestation of pain in childhood. Estimates of the prevalence of headache in children and adolescents vary widely (depending on the setting, methodology, and diagnostic criteria applied) and the impact is not well understood.

AIM

To quantify the impact of headache in a school population.

DESIGN OF STUDY

A questionnaire survey.

SETTING

Exeter schools.

METHOD

A total of 1037 school children between the ages of 12 and 15 years were surveyed, of whom 49% were female. Main outcome measures were headache frequency, disease-specific impact using the Pediatric Migraine Disability Assessment Score (PedMIDAS), and generic quality of life impact using the Pediatric Quality of Life Inventory (PedsQL4).

RESULTS

Twenty per cent of the study population had headache one or more times a week, with an average PedMIDAS score of over 12.1 (and an impact on over 12 days in a 3-month period). Ten per cent of the population had a PedMIDAS score of 16.8 and a PedsQL4 generic quality of life score of 70.1, indicating a poorer quality of life than that of children with asthma, diabetes, or cancer. An average of 0.6 days of school was lost in a 3-month period across all school children.

CONCLUSION

There is a significant impact of headache on the quality of life of children. This impact is both unrecognised and unmet. GPs have an important role in identification and management of this problem.

Prophylactic drugs and cytokine and leptin levels in children with migraine

The study objective was to evaluate levels of the cytokines tumor necrosis factor alpha, interleukin-1beta, and interleukin-6 and of leptin, and then to determine the relationship between these levels and clinical responses in children with migraine after prophylactic therapy with one of four drugs. In all, 77 children who needed prophylactic drugs were treated with cyproheptadine, amitriptyline, propranolol, or flunarizine. Serum levels of the cytokines and leptin were measured before and 4 months after the treatment. Results were compared by drug for headache frequency, severity, and duration, the PedMIDAS score, and levels of each cytokine and of leptin. Each of the four drugs not only decreased the frequency and duration but also the severity of headache, and the PedMIDAS score. None of the drugs was found to be superior to others in terms of reduction in cytokine levels (P > 0.05). Both cyproheptadine and flunarizine (but not amitriptyline and propranolol) caused an increase in leptin levels (P < 0.05). These data suggest that cytokine levels are related to clinical responses, and might help in objective evaluation of clinical response in migraine. To our knowledge, the present study is the first trial to compare the effects of prophylactic drugs, cytokine levels, and leptin levels in children with migraine.

Effects of Gender and Age on Paediatric Headache

The aim of this study was to evaluate the impact of gender and age on headache characteristics and disability. Headache characteristics were assessed at an initial visit to a paediatric specialty care centre and five follow-up visits. A total number of 4121 patients were evaluated. Fifty-eight per cent of the sample was female. Boys were younger at their first headache and initial visit. They more frequently described headache pain as squeezing and location as top of the head. Girls reported more frequent and longer headaches. Girls more often described headache pain as sharp and location as back of the head. Age accounted for more variance than gender in headache severity, duration, frequency and disability. Gender differences exist in headache characteristics. Age is also an important factor in the variability in characteristics and disability. Longitudinal studies are needed to describe further the natural history of headaches in childhood and compare outcome between genders.

Plasma Calcitonin Gene-Related Peptide in Diagnosing and Predicting Paediatric Migraine

To investigate the role of plasma calcitonin gene-related peptide (CGRP) in paediatric migraine, we prospectively collected 134 blood samples during or between attacks from 66 migraine, 33 non-migraine headache (non-migraine) and 22 non-headache patients, aged 4–18 years. Plasma CGRP concentrations were measured by enzyme-linked immunosorbent assay and disability by Pediatric MIgraine Disability ASsessment (PedMIDAS) questionnaire. Migraineurs had higher plasma CGRP levels than non-migraine patients ( P = 0.007). The attack level was higher than the non-attack level in migraine ( P = 0.036), but not in non-migraine, patients. This was also revealed in paired comparison ( n = 9, P = 0.015 vs. n = 4, P = 0.47). Using a threshold of 55.1 pg/ml, the sensitivity of the attack level in predicting migraine was 0.81, and specificity 0.75. The PedMIDAS score tended to be higher in the high CGRP (> 200 pg/ml, n = 7) group than in the low (< 200 pg/ml, n = 33) group (26.07 vs. 19.32, P = 0.16) using Mann–Whitney test. Plasma CGRP is useful for diagnosis in paediatric migraine.

Caring for Student-Athletes Following a Concussion

The school nurse plays a dynamic role in the care and treatment of a concussed athlete. Concussions in the adolescent populations are of special concern due to their potential impact on mental development and cognitive function, as well as an increased risk of serious complications including second impact syndrome. The complexity of a concussion requires collaboration between of a variety of health care and school personnel to create an optimal situation for the student-athlete and their family. As the primary health care provider for students during the school day, school nurses can help ensure all necessary steps are taken to aid the recovery of an injured student-athlete. It is important that school nurses are up-to-date on current concussion information to allow for optimal care following injury and during the recovery process.

Serotonin effects on sleep and emotional disorders in adolescent migraine

OBJECTIVE

To determine frequency of emotional disorders and sleep disturbances in adolescent migraineurs with episodic and chronic headaches. To determine the relationship of whole blood serotonin, caffeine consumption, and frequency of sleep and mood disorders.

BACKGROUND

The neurotransmitter serotonin has been implicated to play a role in the initiation and maintenance of sleep and in modulating mood. A putative role in migraine pathophysiology is also known.

METHODS

Adolescents from 13 to 17 years of age were identified from our headache clinic with episodic or chronic migraine (according to International Classification of Headache Disorders-Second Edition criteria) and healthy controls enrolled. Psychological rating scales were completed, including Adolescent Symptom Inventory (4th Edition) and Child Depression Inventory. Sleep questionnaires (Pediatric Sleep Questionnaire and Child Sleep Habit Questionnaire) were completed by the teenager's parents/guardian. Whole blood serotonin levels were drawn and analyzed and caffeine consumption obtained by history.

RESULTS

A total of 18 controls (8 girls) and 15 patients each with episodic migraines (9 girls) and chronic migraine (10 girls) were studied. Patients with headache had significantly more sleep problems than controls. Patients with chronic migraines had increased daytime sleepiness and dysthymia compared with teenagers with episodic migraines. Serotonin levels were not significantly different, and no association was noted between serotonin levels and sleep abnormalities or emotional rating scales. Increased caffeine intake was related to sleep and depressive complaints.

CONCLUSIONS

Sleep and emotional disorders were common in adolescents with migraine. Sleep disorders and dysthymia were more prevalent with increased headache frequency. No correlation was noted with whole blood serotonin levels.

Obesity in the pediatric headache population: a multicenter study

OBJECTIVE

To examine the prevalence of obesity, the relationship between weight compared with headache frequency and disability, and effect of weight change on headache outcomes within a pediatric headache population.

BACKGROUND

Headache and obesity are both common conditions in children and adults. Research in adults has suggested a relationship between the 2 conditions. This relationship has not yet been explored within a pediatric population. The effect of obesity and weight change on headache outcomes may have important implications for clinical care.

METHOD

Data on height, weight, age, and gender, as well as headache frequency and disability, were collected on 913 consecutive patients at 7 pediatric headache centers, the body mass index (BMI) calculated and the BMI percentile determined. The same data were collected on patients seen at 3- (n = 213) and 6-month (n = 174) follow-up for comparative analysis.

RESULTS

The prevalence of overweight patients at initial visit did not significantly differ from the general pediatric population. BMI percentile was significantly correlated with headache frequency and disability at initial visit, although the correlations were relatively small. For children who were obese or at risk for overweight as initial visit, change in BMI was significantly positively correlated with change in headache frequency at 3- and 6-month follow-up.

CONCLUSIONS

Obesity is associated with headache frequency and disability in the pediatric headache population. For children who are overweight, weight loss can contribute to a reduction in headaches over time. Clinicians should consider child weight status in providing care for pediatric headache.

Measuring the Impact of Headache in Children: A Critical Review of the Literature

Headache is the most frequent neurological symptom and commonest manifestation of pain in childhood. Measuring the impact of headache in terms of health status, functioning and quality of life can inform the prioritization of competing resource claims, screen for unmet need, improve communication between patient and physician and monitor response to treatment. We undertook a critical review of the literature measuring the impact of headache in children and identified 33 papers that contained relevant information. Findings reflected a wide range of settings, age groups, methodologies and outcome measures. Considerable methodological limitations affected all studies, including inadequate description of study design, methodology and data analysis. Nevertheless, although we found the existing literature to be of inconsistent quality, the impact of headache in children and adolescents is substantial. Rigorous studies are required to quantify this burden using measures that are valid and reliable and whose development has been informed by both theoretical and practical perspectives.

Anticonvulsant drugs for pediatric migraine prevention: an evidence-based review

BACKGROUND

The use of anticonvulsant drugs for the prevention of migraine in children and adolescents has been supported in the past.

AIMS

To evaluate the available evidence for the efficacy and safety of anticonvulsants drugs in the prevention of migraine attacks in children and adolescents.

METHODS

Studies were selected through a comprehensive literature search. We included all types of study designs (controlled and uncontrolled) due to the limited evidence. Monthly migraine frequency was used as the primary outcome measure in most of the studies. Studies were classified into levels of evidence according to their design.

RESULTS

Fourteen studies were included with a total of 939 patients. Topiramate (4 randomized controlled trials [RCT], two uncontrolled trials), sodium valproate/divalproex sodium (two RCTs, one uncontrolled trial, two retrospective chart reviews) levetiracetam and zonisamide (both only uncontrolled studies) are the anticonvulsants that have been reported in the literature. The findings show that valproate is not different from placebo and topiramate may not be different but further randomized trials are needed. All drugs were well tolerated in this age group with no serious events reported.

CONCLUSIONS

The use of anticonvulsants in the prevention of migraine in children and adolescents is not adequately supported by methodologically sound RCTs. More research is needed in the future to establish the efficacy and safety of specific agents.

Comparison of the effectiveness of topiramate and sodium valproate in pediatric migraine

Frequent migraine headaches can have a significant impact on disability, prompting the need for early recognition and treatment. The objective of this study is to compare the efficacy of topiramate and sodium valproate for the prevention of pediatric migraine, retrospectively. Mean monthly migraine frequency, intensity, and duration in the 28 patients treated with topiramate decreased from 15.3 +/- 10.1 to 4.4 +/- 5.5 episode, from 6.8 +/- 1 to 3.2 +/- 1, and from 10.2 +/- 9.4 to 2.4 +/- 3.1 hours, respectively. Headache disability improved with a reduction of Pediatric Migraine Disability Assessment score from 36 +/- 29.5 to 4.6 +/- 6.5 (P < .05). Similarly, mean monthly headache frequency, headache intensity, headache duration, and Pediatric Migraine Disability Assessment score in the 20 patients treated with sodium valproate decreased from 20.1 +/- 10.2 to 6.6 +/- 8.6, from 7.1 +/- 1 to 3.4 +/- 2.1, from 7 +/- 12 to 1.4 +/- 2.5 hours, and from 20.5 +/- 16.1 to 5.5 +/- 9.2, respectively (P < .05). In conclusion, valproate and topiramate seem to be able to manage successfully childhood migraine without substantial differences in efficacy.

[Management of chronic daily headache in children and adolescents]

Chronic daily headache (CDH) affects 2 to 4% of adolescent females and 0,8 to 2% of adolescent males. CDH is diagnosed when headaches occur more than 4 hours a day, for greater than or equal to 15 headache days per month, over a period of 3 consecutive months, without an underlying pathology. It is manifested by severe intermittent headaches, that are migraine-like, as well as a chronic baseline headache. Silberstein and Lipton divided patients into four diagnostic categories: transformed migraine, chronic tension-type headache, new daily-persistent headache, and hemicrania continua. The second edition of the International Classification of Headache Disorders did not comprise any CDH category as such, but provided criteria for all four types of CDH: chronic migraine, chronic tension-type headache, new daily-persistent headache, and hemicrania continua. Evaluation of CDH needs to include a complete history and physical examination to identify any possibility of the headache representing secondary headaches. Children and adolescents with CDH frequently have sleep disturbance, pain at other sites, dizziness, medication-overuse headache and a psychiatric comorbidity (anxiety and mood disorders). CDH frequently results in school absence. CDH management plan is dictated by CDH subtype, the presence or absence of medication overuse, functional disability and presence of attacks of full-migraine superimposed. Reassuring, explaining, and educating the patient and family, starting prophylactic therapy and limiting aborting medications are the mainstay of treatment. It includes pharmacologic (acute and prophylactic therapy) and nonpharmacologic measures (biobehavioral management, biofeedback-assisted relaxation therapy, and psychologic or psychiatric intervention). Part of the teaching process must incorporate life-style changes, such as regulation of sleep and eating habits, regular exercise, avoidance of identified triggering factors and stress management. Emphasis must be placed on preventive measures rather than on analgesic or abortive strategies. Stressing the reintegration of the patient into school and family activities and assessing prognosis are other issues to address during the first visit. There are limited data evaluating the outcome of CDH in children and adolescents.

Validation of a self-report questionnaire version of the Child Activity Limitations Interview (CALI): The CALI-21

The Child Activity Limitations Interview (CALI) is a measure designed to assess functional impairment due to chronic pain in school-age children. In this study, we present a self-report questionnaire version of the CALI (the CALI-21) that extends the original interview measure. The purpose of this study was to provide internal consistency, cross-informant reliability and construct validity of the CALI-21 on a clinical sample of children and adolescents with chronic pain conditions. One hundred fifty-five children and adolescents (65 males, 90 females; ages 8-18 years, M=14.31, SD=2.45) with chronic pain completed questionnaires as part of their clinic intake procedures at their consultation visit in a pediatric pain management clinic. An exploratory factor analysis was conducted to measure latent constructs within the broader domain of functional impairment. Results of the exploratory factor analysis yielded two factors representing limitation in Active and Routine activities on both parent and child reports. Parent and child total CALI scores correlated with measures of pain intensity, however, different patterns of correlations emerged between age, pain intensity, depressive symptoms, and the Active and Routine factors. The CALI-21 showed good internal consistency, high cross-informant reliability, and demonstrated construct validity. The CALI-21 provides increased flexibility via the questionnaire format in the assessment of pain-related activity limitations in children. Factor analysis extends information about specific types of activity limitations experienced by children.

Pediatric headache

PURPOSE OF REVIEW

Headaches occur frequently in the pediatric population and have a significant impact on both the patient and their family. Migraine, the most common headache disorder for which patients see a physician, still remains underdiagnosed and undertreated. Recent studies have revealed the increasing incidence of migraine and chronic migraine in the pediatric population.

RECENT FINDINGS

Limitations of the present diagnostic criteria for migraine are presented, and the proposed modifications to these criteria may assist you with early recognition and ultimate treatment. New acute and preventive migraine treatment data demonstrating statistically significant benefit for the primary endpoints will be reviewed in detail. The clinically relevant impact of migraine on the pediatric patient documented by the use of the Pediatric Migraine Disability Assessment and the Pediatric Quality of Life Inventory will be discussed.

SUMMARY

A comprehensive management approach blending the most current acute, preventive, and biobehavioral treatments will be reviewed. Further research, with novel study designs, in pediatric headaches is needed to help reveal additional pathophysiological mechanisms, improve diagnostic criteria, and advance optimal treatment. Prospective studies are needed to fully evaluate the efficacy of preventive management in this population and to establish whether early intervention might slow this disease progression.

Core outcome domains and measures for pediatric acute and chronic/recurrent pain clinical trials: PedIMMPACT recommendations

Under the auspices of the Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials (IMMPACT), 26 professionals from academia, governmental agencies, and the pharmaceutical industry participated in a 2-stage Delphi poll and a consensus meeting that identified core outcome domains and measures that should be considered in clinical trials of treatments for acute and chronic pain in children and adolescents. Consensus was refined by consultation with the international pediatric pain community through announcement of our recommendations on the Pediatric Pain List and inviting and incorporating comments from external sources. There was consensus that investigators conducting pediatric acute pain clinical trials should consider assessing outcomes in pain intensity; global judgment of satisfaction with treatment; symptoms and adverse events; physical recovery; emotional response; and economic factors. There was also agreement that investigators conducting pediatric clinical trials in chronic and recurrent pain should consider assessing outcomes in pain intensity; physical functioning; emotional functioning; role functioning; symptoms and adverse events; global judgment of satisfaction with treatment; sleep; and economic factors. Specific measures or measurement strategies were recommended for different age groups for each domain.

PERSPECTIVE

Based on systematic review and consensus of experts, core domains and measures for clinical trials to treat pain in children and adolescents were defined. This will assist in comparison and pooling of data and promote evidence-based treatment, encourage complete reporting of outcomes, simplify the review of proposals and manuscripts, and facilitate clinicians making informed decisions regarding treatment.

Children and adolescents with headache: what do they need?

Headache is the most frequent neurological symptom and common manifestation of pain in children. The needs of this group are poorly understood. The aim of this study is to quantify the extent of unmet need in a primary care paediatric population. A patient questionnaire survey of 2,425 children between the ages of 8 and 17 and an uncontrolled intervention study was undertaken in a large general practice in England. Headache impact was measured before and 4 months after a headache clinic intervention using the paediatric migraine disability assessment score. A total number of 74 (3%) children accepted an invitation for a headache assessment. However, only 49 (2%) attended for consultation of whom 84% were judged to have migraine. A total number of 43 (58%) had been seen before for a headache by their general practitioner. The median impact score was 17 days headache impact in a 3-month period. An intervention by a general practitioner with an interest in headache significantly reduced the headache impact score. There is a significant need amongst children with headache that can be addressed by interventions well within the capacity of general practitioners. Further studies are needed to explore why so few children with headache present to primary care and when they do, why their needs are not adequately addressed.

Topiramate in the prevention of pediatric migraine: literature review

Pediatric migraine is a disabling condition, which can cause a significant impact on quality of life. Currently, no drugs have been approved by the FDA for its preventive treatment. Our aim was to review the medical literature concerning the efficacy and tolerability of topiramate in the prophylactic treatment of migraine in children and adolescents. A total of five papers were reviewed: two randomized controlled trials (RCTs), a post-hoc subset analysis of adolescents who had been included in three RCTs carried out on adults and two open studies. Topiramate has been proven to reduce headache frequency and the accompanying disability. The frequency of side effects varied considerably among studies, the most frequent being weight loss, anorexia, abdominal pain, difficulties in concentrating, sedation and paresthesia. Since these adverse events, although often transitory, may be distressing for the child, we strongly recommend to assess the disability caused by the migraine episodes before deciding to initiate a prophylactic treatment. Nevertheless, dropout rates due to side effects in the studies were very low.

Management of migraine in adolescents

Headaches in children and adolescents are still under-diagnosed. 75% of children are affected by primary headache by the age of 15 with 28% fitting the ICHD2 criteria of migraine. Migraine is considered a chronic disorder that can severely impact a child's daily activities, including schooling and socializing. Early recognition and aggressive therapy, with acute and prophylactic treatments, as well as intensive biobehavioral interventions, are essential to control the migraine attacks and reverse the progression into intractable disabling headache.

Management of chronic daily headache in children and adolescents

Chronic daily headache (CDH) occurs in 1-2% of children and adolescents. It can evolve from either episodic tension-type headache or episodic migraine, or can appear with no previous headache history. As with other primary headache disorders, treatment is based on the level of disability. There are children and adolescents who cope well, but there are others who are markedly disabled by their chronic headaches. As in adults, children and adolescents with CDH are at risk for medication overuse. CDH is a diagnosis of exclusion, based on a thorough history, normal physical examination, and negative neuroimaging findings. Along with the chronic headaches, children with this condition may have co-morbid sleep problems, autonomic dysfunction, anxiety, and/or depression. Principles of treatment include identifying migrainous components, stopping medication overuse, stressing normalcy, using rational pharmacotherapy, and addressing co-morbid conditions. Successful outcomes often involve identifying an appropriate headache preventative, reintegration into school, and family participation in resetting realistic expectations.

Friendships and social interactions of school-aged children with migraine

We set out to evaluate the friendships and social behaviour of school-aged children with migraine. Concern exists regarding the impact of paediatric migraine on daily activities and quality of life. We hypothesized that children with migraine would have fewer friends and be identified as more socially sensitive and isolated than comparison peers. Sixty-nine children with migraine participated in a school-based study of social functioning. A comparison sample without migraine included classmates matched for gender, race and age. Children with migraine had fewer friends at school; however, this effect was limited to those in elementary school. Behavioural difficulties were not found. Middle-school students with migraine were identified by peers as displaying higher levels of leadership and popularity than comparison peers. Concern may be warranted about the social functioning of pre-adolescent children with migraine; however, older children with migraine may function as well as or better than their peers.

Diagnosing and managing headache in children

Once the correct diagnosis of migraine in a child is established, a treatment plan can be developed. This often entails a combination of acute therapies, preventive therapies, and biobehavioral interventions. Goals of treatment should be clearly established for the patients and parents, and realistic time courses discussed. Overall outcome in terms of disability and quality of life also may need to be addressed and included within the evaluation and management scheme.

Emotional problems and prevalence of medication overuse in pediatric chronic daily headache

Chronic daily headaches are an increasingly recognized neurologic issue in children. Frequent headaches can be a source of significant disability and family discord with work/school absenteeism. Medication overuse and emotional disorder would significantly impact treatment and progression. This study examined the frequency of emotional and behavioral problems in children and adolescents with chronic daily headache compared with age-related healthy controls. Prevalence of medication overuse in this chronic daily headache group was evaluated. Otherwise healthy children and adolescents with chronic daily headache (according to International Classification of Headache Disorders-II criteria) were enrolled from the Headache Clinic. Healthy controls were prospectively enrolled from physician offices. Multiple psychological rating scales, headache diaries, presence of medication overuse, and disability surveys (Pediatric Migraine Disability Assessment Survey) were completed. A total of 57 healthy controls and 70 patients were studied. The sample consisted largely of females, many of whom (60%) had medication overuse before medical treatment. Headache patients had significantly more symptoms of anxiety, depression, and somatization compared with controls. Patients with chronic daily headache were at higher risk for emotional disorders, and medication overuse was a significant occurrence, suggesting a need for multisystem treatment approach.

Headaches

PURPOSE OF REVIEW

Headaches and migraine occur frequently in children and adolescents and may have a significant impact on the child's and parents' lives. Recent advances in diagnosis, epidemiology, and treatment have improved the outcomes of children with headaches. This review summarizes some of these findings.

RECENT FINDINGS

Recent studies have revealed the increasing incidence of migraine and chronic migraine in the pediatric and adolescent age groups. These studies have also begun to identify comorbidities that may affect the impact over a lifetime. Limitations of the diagnosis of migraine have restricted some of these findings, but modifications to the criteria may assist with early recognition. Proper evaluation and treatment, including acute, preventive, and biobehavioral therapies, may need to be incorporated for optimal outcomes. Long-term outcomes may be determined by the underlying pathophysiology as well as early effective management.

SUMMARY

Migraine in children is increasingly being recognized as a problem. Early, effective treatment is available and may result in long-term benefit and prevent disease progression. Further research into childhood headaches should help reveal additional pathophysiological mechanisms and treatment options.

Headache in German children and adolescents: a population-based epidemiological study

The aim of the present study was to assess the distribution and characteristics of headache in children aged 7-14 years in Lower Saxony (Germany). For the survey, 8800 households with children were randomly drawn from community registers. Parents received comprehensive questionnaires regarding various aspects of their child's headache history and general health by mail. The response rate was 63.5%. The 6-month prevalence of paediatric headache was 53.2% and increased with age (39% at 7 years to 63% at age 14). Overall, recurrent headache (> or =1/week) was experienced by 6.5% of the total sample and was significantly more common among older girls (> or =11 years) than their male counterparts. Boys and girls did not differ markedly from one another regarding headache occurrence and frequency until the age of 11. Mean age of headache onset was 7.5 years, with onset occurring at a significantly younger age among boys than among girls. In accordance with International Classification of Headache Disorders-II criteria, migraine was diagnosed in 7.5% and tension-type headache in 18.5% of the cases, hence a large proportion of the children had unclassifiable headache. Of the headache disorders, migraine was rated the most disabling, with the highest average intensity, highest frequency, duration of headache often exceeding 2 h and more frequent use of medication. In general, aura symptoms were rare except for visual disturbances (17%). Paediatric headache was strongly associated with other health problems, including other pain symptoms. Paediatric headache was also associated with a history of parental headache.

Topiramate in the prophylaxis of pediatric migraine: a double-blind placebo-controlled trial

Several large, randomized controlled trials have demonstrated the efficacy of topiramate in migraine prophylaxis in adults. However, there are limited data about the use of topiramate in migraine prophylaxis in children. We conducted this single-center, double-blind, placebo-controlled trial to evaluate the efficacy and safety of topiramate in the prophylaxis of migraine in children. A total of 44 children with migraine were randomized using random number tables to receive topiramate (n = 22) or placebo (n = 22). The total duration of treatment was 4 months, including a baseline period of 1 month during which topiramate was titrated weekly in 25-mg increments to 100 mg/d in 2 divided doses or to the maximum tolerated dose. The titration was followed by a 12-week maintenance phase during which topiramate was given in 2 divided doses. The primary outcome measures were the reduction in the mean migraine frequency and severity of headache. Secondary outcome measures included the number of times analgesics were required for a month for acute attacks and functional disability. Functional disability was measured by comparing school absenteeism and Pediatric Migraine Disability Assessment Scale (PedMIDAS). The decrease in mean (+/-SD) monthly migraine frequency from 16.14 (+/-9.35) at baseline to 4.27 (+/-1.95) at the end of the study in the topiramate group was significantly greater as compared with a decrease from 13.38 (+/-7.78) to 7.48 (+/-5.94) at the end of the study in the placebo group (P = .025). The difference in number of rescue medications used for topiramate and placebo was not statistically significant (P = .059). There was a statistically significant decrease in the PedMIDAS score from 50.66 (+/-32.1) to 10.42 (+/-6.39) at the end of the study in the topiramate group compared with a decrease from 42.66 (+/-27.5) to 23.7 (+/-19.1) at the end of 4 months in the placebo group (P = .003). The decrease in school absenteeism was significant with topiramate compared with placebo (P = .002). Weight loss, decreased concentration in school, sedation, and parasthesias were important side effects with topiramate. Most of these side effects were mild to moderate and were not significant enough to cause dropout from the study.

Headache in children with sickle cell disease: prevalence and associated factors

OBJECTIVE

To compare the prevalence of frequent headache in children with sickle cell disease (SCD) to that of black control subjects and to assess factors associated with headache in SCD.

STUDY DESIGN

In this cross-sectional study, a headache questionnaire was administered to subjects with SCD and black control subjects. Subjects answered supplementary questions about SCD complications. Clinical and radiographic information were abstracted from medical charts for subjects with SCD.

RESULTS

Children (n = 241) with SCD and 141 control subjects were studied; 32.4% (95% CI 26.5%-38.7%) of subjects with SCD reported having headaches at least weekly, similar to control subjects at 27% (95% CI 19.8%-35.1%, P = NS); however, in children <13 years, headache was more common in subjects with SCD than in control subjects (24% vs 9.7%, P = .013). The prevalence of headache was similar among the different SCD genotypes. Factors associated with frequent headaches in subjects with SCD included older age, frequent vaso-occlusive pain episodes, symptoms of obstructive sleep apnea, and cerebral vessel stenosis detected by magnetic resonance angiography.

CONCLUSION

The prevalence of headaches in children with SCD is similar to the general population; however, younger children with SCD report headaches more frequently than control subjects. The cause of headache is likely multifactorial, and SCD-specific factors may contribute.

Levetiracetam prophylaxis in pediatric migraine--an open-label study

BACKGROUND

Migraine is common in the pediatric population. Levetiracetam, an anti-epileptic drug, has shown some efficacy in small prospective adult headache studies.

METHODS

We prospectively evaluated levetiracetam in an open-label study in 20 pediatric migraine patients to assess tolerability and efficacy.

RESULTS

Eighteen of 20 patients had significant reduction in headache frequency. PedMIDAS showed significant decrease in disability scores, side effects were minimal (mild behavioral changes).

CONCLUSION

Levetiracetam had some efficacy in reducing migraine frequency and disability. Further larger studies are warranted, possibly utilizing a placebo-controlled design.

Coenzyme Q10 Deficiency and Response to Supplementation in Pediatric and Adolescent Migraine

BACKGROUND

Coenzyme Q10 (CoQ10) has been suggested to be effective in the prevention of migraine, and levels can be quantified with standardized reference ranges.

OBJECTIVE

This study documents the prevalence of CoQ10 deficiency in migraine headache and examines the potential effectiveness of supplementation.

METHODS

We assessed patients attending a tertiary care center with frequent headaches for CoQ10 deficiency. We recommended patients with low CoQ10 levels begin supplementation with CoQ10 as part of their multidisciplinary treatment plan. We assessed response to treatment including correction of CoQ10 deficiency, overall headache improvement, and headache disability.

RESULTS

CoQ10 was measured in 1550 patients (mean age 13.3 +/- 3.5, range 3 to 22 years). The mean total CoQ10 level was 0.60 +/- 0.20 microg/mL (range 0.21 to 1.77 microg/mL). Of these patients, 32.9% were below the reference range. Patients with low CoQ10 were recommended to start 1 to 3 mg/kg per day of CoQ10 in liquid gel capsule formulation. In a subset of patients who returned for timely follow-up (mean, 97 days), the total CoQ10 level improved to 1.20 +/- 0.59 microg/mL (P < .0001), while the headache frequency improved from 19.2 +/- 10.0 to 12.5 +/- 10.8 (P < .001) and headache disability assessed with PedMIDAS improved from 47.4 +/- 50.6 to 22.8 +/- 30.6 (P < .001).

CONCLUSIONS

Deficiency of CoQ10 may be common in pediatric and adolescent migraine. Determination of deficiency and consequent supplementation may result in clinical improvement. Further analysis involving more scientifically rigorous methodology will be required to confirm this observation.

Chronic daily headaches in children

Chronic daily headache (CDH) is increasingly recognized as a problem in pediatrics and tertiary pediatric headache care. It is estimated that up to 4% of the adult population has CDH. Many of these are chronic migraine (CM). The fraction of the pediatric population with CDH appears to be lower, although the prevalence has not been adequately determined. The simplest definition of CDH is more than 15 headache days per month. In the International Classification of Headache Disorders, Second Edition (ICHD-II), several types of CDH have been identified. These criteria have been contrasted with the Silberstein-Lipton criteria, with revisions suggested. The diagnosis of CDH is further complicated and may be initiated by the overuse of analgesic medications (medication overuse headache) and requires the resolution of this issue before a final diagnosis can be established. In children, most CDH appears to have migraine features, although it may not completely meet the ICHD-II criteria for migraine or CM. Evaluation of CDH needs to include a complete history and physical examination to identify any possibility of the secondary headaches or headaches directly attributed to a secondary cause. Treatment and management involve a multidisciplinary approach, including acute therapy for when the headache severity increases (while avoiding medication overuse), preventative therapy to reduce the frequency and impact of the CDH, and biobehavioral therapy to assist with long-term outcome.

Pediatric headache

Migraine is very treatable in children and adolescents. Principles of treatment include early intervention, elimination of triggers, involvement of parents and schools, and judicious use of medicines. Although there is no pediatric indication in the United States, triptans are safe and effective in this age group. Prophylactic drugs should be used when significant disability from migraine exists. Choice of drug is based upon comorbidity. Nonpharmacologic treatment has an important role.

Topiramate for Migraine Prevention in Adolescents: A Pooled Analysis of Efficacy and Safety

OBJECTIVE

To characterize the efficacy and safety of topiramate for migraine prevention in adolescents from 3 randomized, 26-week, double-blind, placebo-controlled trials.

BACKGROUND

Limited information is available regarding the efficacy and safety of prophylactic medications for treatment of adolescent migraine, a significant health problem. In studies that included adults and children, topiramate 100 and 200 mg/day were effective and generally well-tolerated in the prevention of migraine headache.

METHODS

We performed a post hoc subset analysis of the efficacy and safety data from the 51 patients, ages 12-17 years, enrolled in 3 pivotal trials of topiramate for migraine prophylaxis.

RESULTS

Daily treatment with topiramate 50, 100, and 200 mg for 26 weeks reduced monthly migraine frequency from baseline 46% (P= .07), 63% (P= .02), and 65% (P= .04), respectively, compared with placebo (16%). Similarly, topiramate reduced both the monthly mean number of migraine days (1, 4, and 5 days for topiramate 50, 100, and 200 mg/day, respectively, vs 1 day for placebo) and percentage of days during which acute migraine medications were administered (59%, 54%, and 67% for topiramate 50, 100, and 200 mg/day, respectively, vs 42% for placebo), although the treatment differences did not reach nominal statistical significance. Topiramate 200 mg/day did not appear to offer greater efficacy than 100 mg/day. Treatment was generally well-tolerated, although adverse events were most frequent in the 200 mg/day dose group.

CONCLUSIONS

This post hoc subset analysis suggests that topiramate 100 and 200 mg/day, and possibly 50 mg/day, administered prophylactically for 26 weeks may reduce migraine in adolescents.

Pharmacologic treatment of migraine

Nonsteroidal anti-inflammatory drugs are the mainstay of migraine treatment for children and adolescents by most primary care physicians. Not all patients respond to these readily available agents. Triptans have been studied in children and adolescents, and there is reasonable evidence to support the use of these agents in these populations. Other agents, such as combination preparations and ergot compounds, are also used in clinical practice, although there has been little scientific study. Prophylactic agents have been less well studied in those under 18 years of age. Agents such as antidepressants, anticonvulsants, and antihypertensives are commonly used in clinical practice. Safety issues are fairly well understood because of historical use and use for other conditions. Efficacy and optimal dosing have yet to be established for the treatment of migraine in children and adolescents in double-blind, randomized, placebo-controlled trials.

The associations among childhood headaches, emotional and behavioral difficulties, and health care use

BACKGROUND

Headaches are common among children and adolescents, particularly migraine and tension-type headaches. They contribute to missed school days, affect children's peer and family relationships, and significantly impact children's quality of life, often times into adulthood.

OBJECTIVES

This study, based on responses to the Strengths and Difficulties Questionnaire, was designed to examine difficulties and impairments related to emotions, concentration, behavior, and social functioning among children with frequent or severe headaches (FSH).

METHODS

We used a cross-sectional study of 9264 children aged 4-17 years from the 2003 National Health Interview Survey, an ongoing, computer-assisted personal interview survey of the noninstitutionalized US population.

RESULTS

Approximately 6.7% of children experienced FSH during the previous 12 months. Overall, children with FSH were 3.2 times more likely than children without FSH to have a high level of difficulties and 2.7 times more likely to have a high level of impairment, suggesting potential mental health issues. More specifically, analyses revealed that children with FSH were significantly more likely than those without FSH to exhibit high levels of emotional, conduct, inattention-hyperactivity, and peer problems and were significantly more likely than children without FSH to be upset or distressed by their difficulties and to have their difficulties interfere with home life, friendships, classroom learning, and leisure activities.

CONCLUSION

Because children with FSH experience notable pain, mental health issues, and functional limitations, integrated care using a biopsychosocial approach is warranted.

Age-Dependent Relationships Among Pain, Depressive Symptoms, and Functional Disability in Youth With Recurrent Headaches

OBJECTIVE

To assess age differences associated with depressive symptoms and functional disability in children and adolescents with recurrent headache.

BACKGROUND

Research has indicated that psychological factors, especially depression, are related to the extent and nature of functional disability experienced from headaches. There is a lack of research examining how age impacts the relationship between pain, psychological factors, and activity restriction in children and adolescents with recurrent headache.

METHODS

Seventy-seven participants from a pediatric neurology clinic completed self-report measures of pain intensity, depressive symptoms, and functional disability.

RESULTS

Findings demonstrated a significant positive correlation between pain and functional disability, and depressive symptoms and functional disability for children. Correlations for adolescents failed to reach significance. Functional disability emerged as a mediator between headache pain and depressive symptoms for children but not for adolescents.

CONCLUSIONS

Results indicate potentially important age differences when examining the impact of functional disability on depressive symptoms in this sample. Findings suggest that functional disability may contribute to depressive symptoms differently for children versus adolescents with recurrent headache. Age-specific interventions that differentially focus on the specific roles that pain, depressive symptoms, and disability have for children and adolescents with recurrent headache may be warranted.

Behaviour during attacks and assessment of intensity in primary headaches of children and adolescents

Assessment of attack intensity in primary headaches of paediatric age has not received great attention in the literature to date and in the international classification the criteria to define pain intensity are also not specified. The purpose of this research was to evaluate whether behaviour during attacks, reported by the child or a parent, can be used as a measure of attack disability, and so as an indirect measure of attack intensity in primary headaches of children and adolescents. The subjects were 320 patients aged between 3 and 14 years (mean age 9.9 years, SD 2.6 years) affected by primary recurrent headaches and first seen at a headache clinic. Twelve variables taken from their history were considered and sequentially analysed with multiple correspondence analysis and cluster analysis. Five types of behaviour during attacks were identified: (i) the child (or the parent) is unable to answer the questions or the child has no limitation in activities; (ii) the child may have some activity limitation, but only in lively games; (iii) the child has limitations in daily life with regard also to quiet activities; (iv) at least during some attacks the child lies down with closed eyes or in the dark; (v) during each attack the child lies down with closed eyes or in the dark. The least important variables for the identification of the five behaviour types were studying at school and absence from school. There are some limitations in considering child's behaviour as a measure of attack intensity/disability; one of these is the fact that it was found to be related to the educational level of the mother. However, behaviour during attacks, reported by the child or the parent, provides useful information independently of child's age and, together with the score of pain, when this is given, it can be used as measure of attack intensity.

Do children and adolescents have chronic daily headaches? Yes!

Chronic daily headaches in children and adolescents appear to have been increasing throughout the past few decades. The diagnosis, classification, treatment, and long-term prognosis continue to be poorly understood. Recent epidemiologic studies and updated classifications have been done in this area, but further work is needed to help these children.

Treatment of pediatric and adolescent headaches

The treatment of childhood headaches requires a thorough investigation of the underlying etiology, including the use of standardized diagnostic criteria, and neurologic and comprehensive examinations. If secondary headaches are identified, the headaches should resolve with treatment of the underlying cause. If the headaches persist or primary headaches are identified, a three-component treatment approach may need to be developed. This includes acute therapy, preventative therapy, and biobehavioral therapy. All of these components need to be addressed in the treatment of childhood headaches, and clear goals of treatment must be discussed with the patient and parents.

What is the impact, prevalence, disability, and quality of life of pediatric headache?

Pediatric headache is a common health problem in children, with a significant headache reported in more than 75% by the age of 15 years. Pediatric migraine occurs in up to 10.6% of children between the ages of 5 and 15 years and in up to 28% of adolescents between the ages of 15 and 19 years. Given this high frequency, the impact of this disease on the lives of these children and their parents can be quite significant. This impact can be assessed with disease-specific disability and impairment as well as disease non-specific effects on quality of life. The goal of evaluation should be recognition of this impact, whereas the goal of management should be effective treatment that minimizes the impact of this disorder in the short term and for the life of the patient.

Methodological considerations in research with special populations: children and adolescents

Headache occurs across the lifespan, but limited attention has been devoted to children and adolescents. This article discusses pertinent methodological considerations when conducting behavioral research with pediatric populations. Issues needing special consideration when working with children and adolescents involve ethics, sample characterization, headache diagnosis, treatment administration, and outcome measurement. Available literature is reviewed and specific recommendations are offered when possible.

Assessing health-related quality of life in children with recurrent headache: reliability and validity of the PedsQLTM 4.0 in a pediatric headache sample

OBJECTIVE

To evaluate the reliability and validity of a commonly used measure of health-related quality of life (HRQOL), the Pediatric Quality of Life Inventory (PedsQL 4.0), in a sample of children with a recurrent headache syndrome.

METHODS

Participants were 40 children aged 7-12 who completed measures of HRQOL, headache-related disability, and headache activity during a baseline period and following a self-directed cognitive-behavioral intervention.

RESULTS

The data are supportive of the reliability (internal consistency and test-retest) and validity (criterion related, convergent, known-groups, and responsiveness to intervention) of the PedsQL 4.0 within a pediatric headache sample.

CONCLUSIONS

We conclude that the PedsQL 4.0 is a reliable and valid measure of HRQOL in children with recurrent headache and captures important information not routinely evaluated in chronic pain populations.

Development and psychometric properties of a pain-related problem list for adolescents (PPL)

Instruments for measuring pain-related problems in adolescents with chronic pain are sparse, especially those based on the personal experiences of these adolescents. This study aimed to develop and test such an instrument, the pain-related problem list for adolescents (PPL). A sample of 129 adolescents with chronic pain without documented physiological etiology completed the 57-item problem list, which was based on interviews with a similar group of adolescents with chronic pain. Principal components analysis yielded four domains: problems related to (1) concentration; (2) mobility; (3) adaptability; and (4) mood. The questionnaire was shortened to 18 items and has good reliability (total alpha = 0.82; concentration alpha = 0.86; mobility alpha = 0.77; adaptability alpha = 0.71; and mood alpha = 0.78); the validity also proved to be adequate, especially in the general population sample. The PPL provides a tool to assess the impact of chronic pain in adolescents. Future research should focus on further validation of the PPL in a large clinical population and establishing its test-retest reliability.

Long-term tolerability of sumatriptan nasal spray in adolescent patients with migraine

OBJECTIVE

This 1-year, open-label, multicenter study was designed to assess the long-term tolerability and efficacy of sumatriptan nasal spray 20 mg in adolescent patients with migraine.

METHODS

A prospective, multicenter, open-label study was conducted in patients aged 12 to 17 years who were allowed to treat an unlimited number of migraines at severe, moderate, or mild pain intensity with sumatriptan nasal spray for up to 1 year. All patients started the study at the 20-mg dose of sumatriptan nasal spray. Dose could be adjusted downward to 5 mg at the discretion of the investigator to optimize therapy.

RESULTS

A total of 484 adolescent migraineurs treated 4676 migraines with sumatriptan nasal spray 20 mg (3593 during the first 6 months and 1083 during the second 6 months). A total of 3940 migraines and 699 migraines were treated with one and two 20-mg doses of sumatriptan nasal spray, respectively. Only 10 patients (treating 42 migraines) took the 5-mg dose of sumatriptan nasal spray. The overall percentage of migraines treated with either one 20-mg dose or one, two, or three 20-mg doses with at least 1 drug-related adverse event was 19%. The most common specific drug-related adverse event was unpleasant taste, reported in 17% of migraines. No other single drug-related adverse event was reported in more than 1% of migraines over the 1-year treatment period. When unpleasant taste was excluded from the adverse-event tabulations, the percentages of migraines with at least 1 drug-related adverse event after one or one, two, or three 20-mg doses declined to 4% and 3%, respectively. No patient experienced any drug-related changes in 12-lead ECGs, vital signs, or nasal assessments; and no clinically meaningful changes in clinical laboratory values were observed. Across all migraines with evaluable efficacy data (n=4334), headache relief was reported in 43% of migraines at 1 hour and in 59% at 2 hours after dosing with sumatriptan nasal spray 20 mg. Of the 2561 migraines with headache relief 2 hours postdose, headache recurrence was reported within 24 hours of initial dosing in 7% of migraines. None of the efficacy or tolerability results varied as a function of time in the study (ie, first 6 months vs. second 6 months).

CONCLUSION

Sumatriptan nasal spray 20 mg is generally well tolerated and may be beneficial during long-term use by adolescent migraineurs ages 12 to 17 years.