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Puliappadamb HM, Satpathy AK, Mishra BR, Maiti R, Jena M. Evaluation of Safety and Efficacy of Add-on Alpha-Lipoic Acid on Migraine Prophylaxis in an Adolescent Population: A Randomized Controlled Trial. J Clin Pharmacol 2023; 63:1398-1407. [PMID: 37563914 DOI: 10.1002/jcph.2331] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Accepted: 08/07/2023] [Indexed: 08/12/2023]
Abstract
Nutraceuticals like alpha-lipoic acid (ALA) may have potential benefits as prophylactic agents for adolescent migraine, with fewer adverse events than existing medications. The present study was conducted to evaluate the safety and efficacy of add-on ALA for prophylaxis in adolescent migraine. A randomized, open-label, add-on clinical trial was conducted with 60 adolescent migraineurs, who were randomized to receive flunarizine or flunarizine with an add-on ALA. A clinical evaluation of the frequency and severity of migraine, responder rate, Pediatric Migraine Disability Assessment (PedMIDAS) scoring, serum thiol, and serum calcitonin gene-related peptide (CGRP) was performed both at baseline and following 12 weeks of treatment. The frequency of acute attacks of migraine decreased significantly (P = .001) in the test group compared with the control group. The responder rate was found to be significantly higher (80%) in the test group than in the control group (33.3%) (P = .001). The mean monthly migraine headache days in the test group showed a significant reduction (-7.7 days, 95%CI -9.1 to -6.3 days; P = .010). The severity of acute migraine attacks (mild, moderate, severe) also showed a significant reduction in the test group (P = .001). PedMIDAS scores showed significant improvement in the test group (P = .021), in comparison with the control group. Serum thiol levels were significantly increased in the test group (18 mmol/L, 95%CI 13.5 to 36.1 mmol/L; P = .001). Serum CGRP levels showed a significant reduction with adjunctive ALA therapy (-122.4 pg/mL, 95%CI -142.3 to -89.0 pg/mL; P = .006). Add-on ALA with flunarizine as a prophylactic agent for migraine in adolescents can improve clinical outcomes by improving clinical and biochemical parameters.
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Affiliation(s)
| | - Amit Kumar Satpathy
- Department of Paediatrics, All India Institute of Medical Sciences (AIIMS), Bhubaneswar, India
| | - Biswa Ranjan Mishra
- Department of Psychiatry, All India Institute of Medical Sciences (AIIMS), Bhubaneswar, India
| | - Rituparna Maiti
- Department of Pharmacology, All India Institute of Medical Sciences (AIIMS), Bhubaneswar, India
| | - Monalisa Jena
- Department of Pharmacology, All India Institute of Medical Sciences (AIIMS), Bhubaneswar, India
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2
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Keerthana D, Mishra D, Chauhan MK, Juneja M. Effect of Propranolol Prophylaxis on Headache Frequency in Children with Migraine Without Aura: A Randomized, Double-Blind, Placebo-Controlled Trial. Indian J Pediatr 2023; 90:880-885. [PMID: 35867273 DOI: 10.1007/s12098-022-04279-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Accepted: 05/11/2022] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To compare the efficacy of propranolol prophylaxis with placebo on headache frequency in children with migraine over the 3-mo follow-up. METHODS In this randomized, double-blind, placebo-controlled trial children aged 6-12 y with newly diagnosed migraine without aura as per the International Classification for Headache Disorders, 3rd edition (ICHD-3) criteria were enroled. They were randomized to the intervention group receiving oral propranolol (1-3 mg/kg/d, BID) and the control group receiving a similar looking, inert, oral placebo for migraine prophylaxis for 3 mo. The number of migraine attacks over the 3-mo follow-up (using a headache diary) was the primary outcome. Pediatric Migraine Disability Assessment Scale (PedMIDAS) was used for assessing disability and Visual analogue scale was used for assessing headache severity. Analysis was done on intention-to-treat basis. RESULTS Twenty children (10 in each group) completed the study. The two groups were similar at baseline. Both the study drugs produced significant reduction of headache frequency after the study intervention (p = 0.002). However, there was no difference between the two groups with respect to either the median (IQR) number of headache attacks [22 (20, 25) vs. 14 (10, 20); p = 0.05], headache severity [1 (0, 1) vs. 0.5 (0, 1); p = 0.48] or migraine disability [39.5 (28, 44) vs. 35 (22, 38); p = 0.27]. Adverse effects were higher in the intervention group (p = 0.52). CONCLUSIONS Propranolol was effective for migraine prophylaxis in children but the effect was not higher than placebo. Larger placebo-controlled trials of propranolol need to be conducted to decide its place in migraine prophylaxis in children. TRIAL REGISTRATION Thailand Clinical Trials Registry; TCTR20200621001.
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Affiliation(s)
- D Keerthana
- Department of Pediatrics, Maulana Azad Medical College (University of Delhi), Lok Nayak Hospital, Delhi, 110002, India.
| | - Devendra Mishra
- Department of Pediatrics, Maulana Azad Medical College (University of Delhi), Lok Nayak Hospital, Delhi, 110002, India
| | - Meenakshi Kanwar Chauhan
- Delhi Institute of Pharmaceutical Sciences and Research (Constituent Institute of DPSR - University), New Delhi, India
| | - Monica Juneja
- Department of Pediatrics, Maulana Azad Medical College (University of Delhi), Lok Nayak Hospital, Delhi, 110002, India
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3
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Davis L, Torphy B. Managing migraine on the frontline: Identifying disease, understanding burden, and incorporating CGRP pathway-targeting therapies in primary care. Br J Pain 2022; 16:560-573. [PMID: 36389011 PMCID: PMC9644104 DOI: 10.1177/20494637221104292] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/03/2023] Open
Abstract
Migraine is a common neurologic disorder with clinical phenotypes encompassing a variety of symptoms which all contribute to the burden felt by patients. In addition to negative impacts on a patient's quality of life, migraine has both direct medical costs and indirect costs related to missed work and decreased productivity that affect individuals as well as society at large. Unfortunately, migraine diagnoses are often missed, and many patients do not receive appropriate treatment. Primary care providers are in a key position to provide timely diagnosis and effectively manage migraine for many patients. This review aims to be a guide for improving migraine management in the primary care setting by providing strategies to overcome common challenges in migraine diagnosis; summarizing current knowledge on the mechanism of action, efficacy, and safety of calcitonin gene-related peptide (CGRP) pathway-targeting therapies; and reviewing approaches to incorporate traditional and emerging treatment options into a patient-centric migraine management strategy.
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Affiliation(s)
- Linda Davis
- Kolvita Family Medical
Group, Mission Viejo, CA, USA
| | - Brad Torphy
- Chicago Headache Center and Research
Institute, Chicago, IL, USA
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4
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Gibler RC, Knestrick KE, Reidy BL, Lax DN, Powers SW. Management of Chronic Migraine in Children and Adolescents: Where are We in 2022? Pediatric Health Med Ther 2022; 13:309-323. [PMID: 36110896 PMCID: PMC9470380 DOI: 10.2147/phmt.s334744] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Accepted: 08/10/2022] [Indexed: 11/23/2022] Open
Abstract
Migraine is a neurological disorder that affects millions of children and adolescents worldwide. Chronic migraine is a subtype of migraine in which patients experience headaches for more days than not each month, with accompanying symptoms of phonophobia, photophobia, nausea or vomiting for most of these headaches. The burden and impact of chronic migraine in the daily lives of children and adolescents is substantial, requiring a holistic, multidisciplinary, and biopsychosocial approach to conceptualization and treatment. The purpose of this review is to provide a comprehensive “2022” overview of acute and preventive treatments for the management of chronic migraine in youth. We first describe diagnostic criteria for chronic migraine and highlight the state of evidence for acute and preventive treatment in children and adolescents. We then discuss emerging treatments currently receiving rigorous clinical research effort, special considerations for the treatment of chronic migraine in children and adolescents, and avenues for improving existing treatments and expanding access to evidence-based care.
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Affiliation(s)
- Robert C Gibler
- Division of Behavioral Medicine and Clinical Psychology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
- Correspondence: Robert C Gibler, Division of Behavioral Medicine and Clinical Psychology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA, Email
| | - Kaelynn E Knestrick
- Division of Behavioral Medicine and Clinical Psychology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
| | - Brooke L Reidy
- Division of Behavioral Medicine and Clinical Psychology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Daniel N Lax
- Division of Neurology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
- Headache Center, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
| | - Scott W Powers
- Division of Behavioral Medicine and Clinical Psychology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
- Headache Center, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
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5
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Iannone LF, De Cesaris F, Geppetti P. Emerging Pharmacological Treatments for Migraine in the Pediatric Population. Life (Basel) 2022; 12:536. [PMID: 35455026 PMCID: PMC9031827 DOI: 10.3390/life12040536,] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2022] [Revised: 03/31/2022] [Accepted: 04/04/2022] [Indexed: 12/07/2023] Open
Abstract
Headaches in children and adolescents have high incidence and prevalence rates, with consequent elevated disability costs to individuals and the community. Pediatric migraine is a disorder with substantial clinical differences compared to the adult form. Few clinical trials have been performed specifically on primary headache in pediatric populations using acute and preventative treatments, often with conflicting findings. The limited high-quality data on the effectiveness of treatments are also due to the high placebo effect, in terms of reductions in both the frequency and intensity of migraine attacks in the pediatric population. The recent introduction of calcitonin gene-related peptide (CGRP) pathway inhibitors and ditans is changing the treatment of migraine, but the majority of the data are still limited to adulthood. Thus, few drugs have indications for migraine treatment in the pediatric age group, and limited evidence gives guidance as to the choice of pharmacotherapy. Herein, we review the current evidence of pharmacological treatments and ongoing clinical trials on acute and preventative treatments in the pediatric population with migraine.
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Affiliation(s)
- Luigi Francesco Iannone
- Section of Clinical Pharmacology and Oncology, Department of Health Sciences, University of Florence, 50121 Florence, Italy;
- Headache Center and Clinical Pharmacology Unit, Careggi University Hospital, 50134 Florence, Italy;
| | - Francesco De Cesaris
- Headache Center and Clinical Pharmacology Unit, Careggi University Hospital, 50134 Florence, Italy;
| | - Pierangelo Geppetti
- Section of Clinical Pharmacology and Oncology, Department of Health Sciences, University of Florence, 50121 Florence, Italy;
- Headache Center and Clinical Pharmacology Unit, Careggi University Hospital, 50134 Florence, Italy;
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6
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Iannone LF, De Cesaris F, Geppetti P. Emerging Pharmacological Treatments for Migraine in the Pediatric Population. Life (Basel) 2022; 12:life12040536. [PMID: 35455026 PMCID: PMC9031827 DOI: 10.3390/life12040536] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2022] [Revised: 03/31/2022] [Accepted: 04/04/2022] [Indexed: 11/16/2022] Open
Abstract
Headaches in children and adolescents have high incidence and prevalence rates, with consequent elevated disability costs to individuals and the community. Pediatric migraine is a disorder with substantial clinical differences compared to the adult form. Few clinical trials have been performed specifically on primary headache in pediatric populations using acute and preventative treatments, often with conflicting findings. The limited high-quality data on the effectiveness of treatments are also due to the high placebo effect, in terms of reductions in both the frequency and intensity of migraine attacks in the pediatric population. The recent introduction of calcitonin gene-related peptide (CGRP) pathway inhibitors and ditans is changing the treatment of migraine, but the majority of the data are still limited to adulthood. Thus, few drugs have indications for migraine treatment in the pediatric age group, and limited evidence gives guidance as to the choice of pharmacotherapy. Herein, we review the current evidence of pharmacological treatments and ongoing clinical trials on acute and preventative treatments in the pediatric population with migraine.
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Affiliation(s)
- Luigi Francesco Iannone
- Section of Clinical Pharmacology and Oncology, Department of Health Sciences, University of Florence, 50121 Florence, Italy;
- Headache Center and Clinical Pharmacology Unit, Careggi University Hospital, 50134 Florence, Italy;
| | - Francesco De Cesaris
- Headache Center and Clinical Pharmacology Unit, Careggi University Hospital, 50134 Florence, Italy;
| | - Pierangelo Geppetti
- Section of Clinical Pharmacology and Oncology, Department of Health Sciences, University of Florence, 50121 Florence, Italy;
- Headache Center and Clinical Pharmacology Unit, Careggi University Hospital, 50134 Florence, Italy;
- Correspondence:
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7
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Lopes CFR, Dos Santos TP, Martins IP. Prognosis of headache in children: a 25-year follow-up. Childs Nerv Syst 2022; 38:619-626. [PMID: 35059785 DOI: 10.1007/s00381-021-05420-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2021] [Accepted: 11/19/2021] [Indexed: 11/03/2022]
Abstract
AIM To describe the natural history, evaluate the long-term prognosis, and identify predictors of a favorable outcome of childhood migraines in a cohort of children who had been diagnosed with migraine 25 years before. METHODS One hundred eighteen children with headache (ages 2 to 15), observed in a headache outpatient clinic of a University Hospital in 1994, by one of the authors, were revaluated in 2019/2020 by a standardized telephone interview specifying headache characteristics, treatment, precipitants, and family history. Headache diagnosis at follow-up was based on ID-Migraine and confirmed by a semistructured interview. RESULTS Revaluation was achieved for 88 (75%) patients (43 with migraine), 47 women and age average 41.2 ± 3.2. Over the follow-up (average 25.5 years), 33% of the patients had experienced remission, 41% maintained the same diagnosis, and 26% evolved into a different headache. Sixty six percent reported an improvement. Only eight patients were attending regular consultations because of headache. Male sex came out as the only predictor of a favorable outcome. CONCLUSION Most patients (66%) with pediatric headache continue to experience headache although reporting a significant improvement. Boys tended to remit more often than girls. This data suggests that age, genetics, and hormonal factors may play an important role in migraine phenotypic expression.
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Affiliation(s)
| | - Tiago Proença Dos Santos
- Neuropediatric Department, Hospital Sta Maria, North Lisbon University Hospital Centre, Lisbon, Portugal
| | - Isabel Pavão Martins
- Headache Outpatient Clinic, Hospital Sta Maria, North Lisbon University Hospital Centre, Neurology Department, Faculty of Medicine, University of Lisbon, Lisbon, Portugal
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8
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Pediatric Headache in Primary Care and Emergency Departments: Consensus with RAND/UCLA Method. Life (Basel) 2022; 12:life12020142. [PMID: 35207430 PMCID: PMC8877535 DOI: 10.3390/life12020142] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Revised: 01/06/2022] [Accepted: 01/12/2022] [Indexed: 01/09/2023] Open
Abstract
Headache is the most frequent neurological symptom in childhood and the main reason for admission to pediatric emergency departments. The aim of this consensus document is to define a shared clinical pathway between primary care pediatricians (PCP) and hospitals for the management of children presenting with headache. For the purposes of the study, a group of hospital pediatricians and a group of PCP from the Emilia Romagna’s health districts were selected to achieve consensus using the RAND/UCLA appropriateness method. Thirty-nine clinical scenarios were developed: for each scenario, participants were asked to rank the appropriateness of each option from 1 to 9. Agreement was reached if ≥75% of participants ranked within the same range of appropriateness. The answers, results, and discussion helped to define the appropriateness of procedures with a low level of evidence regarding different steps of the diagnostic-therapeutic process: primary care evaluation, emergency department evaluation, hospital admission, acute therapy, prophylaxis, and follow-up. The RAND proved to be a valid method to value appropriateness of procedures and define a diagnostic-therapeutic pathway suitable to the local reality in the management of pediatric headache. From our results, some useful recommendations were developed for optimizing the healthcare professionals’ network among primary care services and hospitals.
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9
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Abstract
Pediatric headache impacts up to 80% of children, many recurrently, by the time they are 15 years old. Preventing the progression of episodic to chronic headache results in less truancy, staying current with schoolwork and improves children's quality of life. Lifestyle choices can play an important role in headache treatment. Early effective treatment of episodic headache can prevent transformation into a chronic form. While details of a child's headache are critical for making a proper diagnosis; patient education is critical and effective rescue and preventive treatment strategies enable patients to focus on enjoying activities of daily living. Recognizing "red flags" that may suggest a serious underlying etiology is critical in the early stages of diagnosing and preparing to treat children with headaches. Finally directing patients to manage their headaches at home and when to proceed to an emergency department, urgent care or infusion unit can lower the economic burden of acute headache management.
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Affiliation(s)
- Debra M O'Donnell
- Pediatric Neurologist, Dayton Children's Hospital, Division of Neurology, OH, United States.
| | - Anastazia Agin
- Pediatrician and Headache Specialist, Dayton Children's Hospital, Division of Neurology, OH, United States
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10
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Powers SW, Coffey CS, Chamberlin LA, Ecklund DJ, Klingner EA, Yankey JW, Peugh JL, Korbee LL, Simmons K, Sullivan SM, Kabbouche MA, Kacperski J, Porter LL, Reidy BL, Hershey AD. Prevalence of Headache Days and Disability 3 Years After Participation in the Childhood and Adolescent Migraine Prevention Medication Trial. JAMA Netw Open 2021; 4:e2114712. [PMID: 34251445 PMCID: PMC8276084 DOI: 10.1001/jamanetworkopen.2021.14712] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
IMPORTANCE Migraine is a common neurological disease that often begins in childhood and continues into adulthood; approximately 6 million children and adolescents in the United States cope with migraine, and many frequently experience significant disability and multiple headache days per week. Although pharmacological preventive treatments have been shown to offer some benefit to youth with migraine, additional research is needed to understand whether and how these benefits are sustained. OBJECTIVE To survey clinical status of youth with migraine who participated in the 24-week Childhood and Adolescent Migraine Prevention (CHAMP) trial over a 3-year follow-up period. DESIGN, SETTING, AND PARTICIPANTS This survey study used internet-based surveys collected from youth ages 8 to 17 years at 3, 6, 12, 18, 24, and 36 months after completion of the CHAMP trial, which randomized participants to amitriptyline, topiramate, or placebo. At the end of the trial, the study drug was stopped, and participants received clinical care of their choice thereafter. The CHAMP trial was conducted between May 2012 and November 2015, and survey follow-up was conducted June 2013 to June 2018. Participants in this survey study were representative of those randomized in the trial. Data were analyzed from March 2020 to April 2021. EXPOSURES Survey completion. MAIN OUTCOMES AND MEASURES Headache days, disability (assessed using the Pediatric Migraine Disability Scale [PedMIDAS]), and self-report of ongoing use of prescription preventive medication. RESULTS A total of 205 youth (mean [SD] age, 14.2 [2.3] years; 139 [68%] girls; mean [SD] history of migraine, 5.7 [3.1] years) participated in the survey. Retention of participants was 189 participants (92%) at month 6, 182 participants (88%) at month 12, 163 participants (80%) at month 18, 165 participants (80%) at month 24, and 155 participants (76%) at month 36. Over the course of the 3-year follow-up, participants consistently maintained meaningful reductions in headache days (mean [SD] headache days per 28 days: CHAMP baseline, 11.1 [6.0] days; CHAMP completion, 5.0 [5.7] days; 3-year follow-up, 6.1 [6.1] days) and disability (mean [SD] score: CHAMP baseline, 40.9 [26.4]; CHAMP completion, 17.9 [22.1]; 3-year follow-up, 12.3 [20.0]). At 3 years after completion of the CHAMP trial, headache days were approximately 1.5 per week (changed from about 3 per week at trial baseline) and disability had improved from the moderate range to the low mild range on the PedMIDAS. Longitudinal analyses showed that amitriptyline and topiramate did not explain intercept random effects for either mean rate of headache days per week (amitriptyline: estimate [SE], 0.07 [0.05]; P = .16; topiramate: estimate [SE], 0.04 [0.05]; P = .50) or headache disability PedMIDAS total score (amitriptyline: estimate [SE], 0.25 [0.38]; P = .52; topiramate: estimate [SE], -0.09 [0.39]; P = .82) changes over time. Of 153 participants who reported on prescription drug use at 3 years, only 1 participant (1%) reported using prevention medication, and most participants reported no medication use at most time points. CONCLUSIONS AND RELEVANCE These findings suggest that children and adolescents with longer than 5 years history of migraine who participated in the CHAMP trial may sustain positive clinical outcomes over time, even after discontinuing preventive pill-based treatment. This survey study could inform use and discontinuation timing of pharmacological preventive therapies for migraine in youth ages 8 to 17 years. Research is needed to examine mechanisms of treatment improvement and maintenance for preventive therapies, as well as placebo, in the pediatric population.
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Affiliation(s)
- Scott W. Powers
- Division of Behavioral Medicine and Clinical Psychology, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
- Cincinnati Children’s Headache Center, Cincinnati, Ohio
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Christopher S. Coffey
- Department of Biostatistics, Clinical Trials Statistical and Data Management Center, University of Iowa College of Public Health, Iowa City
| | - Leigh A. Chamberlin
- Division of Behavioral Medicine and Clinical Psychology, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Dixie J. Ecklund
- Department of Biostatistics, Clinical Trials Statistical and Data Management Center, University of Iowa College of Public Health, Iowa City
| | - Elizabeth A. Klingner
- Department of Biostatistics, Clinical Trials Statistical and Data Management Center, University of Iowa College of Public Health, Iowa City
| | - Jon W. Yankey
- Department of Biostatistics, Clinical Trials Statistical and Data Management Center, University of Iowa College of Public Health, Iowa City
| | - James L. Peugh
- Division of Behavioral Medicine and Clinical Psychology, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | | | - Kerry Simmons
- Division of Behavioral Medicine and Clinical Psychology, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Stephanie M. Sullivan
- Office for Clinical and Translational Research, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Marielle A. Kabbouche
- Cincinnati Children’s Headache Center, Cincinnati, Ohio
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
- Division of Neurology, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Joanne Kacperski
- Cincinnati Children’s Headache Center, Cincinnati, Ohio
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
- Division of Neurology, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Linda L. Porter
- National Institute of Neurological Disorders and Stroke, Bethesda, Maryland
| | - Brooke L. Reidy
- Division of Behavioral Medicine and Clinical Psychology, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
- Cincinnati Children’s Headache Center, Cincinnati, Ohio
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Andrew D. Hershey
- Cincinnati Children’s Headache Center, Cincinnati, Ohio
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
- Division of Neurology, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
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11
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Koechlin H, Kossowsky J, Lam TL, Barthel J, Gaab J, Berde CB, Schwarzer G, Linde K, Meissner K, Locher C. Nonpharmacological Interventions for Pediatric Migraine: A Network Meta-analysis. Pediatrics 2021; 147:peds.2019-4107. [PMID: 33688031 DOI: 10.1542/peds.2019-4107] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/12/2021] [Indexed: 11/24/2022] Open
Abstract
CONTEXT Migraine is a common neurologic disorder in children and adolescents. However, a comparison of multiple nonpharmacological treatments is lacking. OBJECTIVE To examine whether nonpharmacological treatments are more effective than waiting list and whether there are differences between interventions regarding efficacy. DATA SOURCES Systematic review and network meta-analysis of studies in Medline, Cochrane, Embase, and PsycINFO published through August 5, 2019. STUDY SELECTION Randomized controlled trials of nonpharmacological treatments in children and adolescents diagnosed with episodic migraine. DATA EXTRACTION Effect sizes, calculated as standardized mean differences (SMDs) for the primary outcome efficacy, were assessed in a random-effects model. RESULTS Twelve studies (N = 576) were included. When interventions were classified into groups on the basis of similarity of treatment components, self-administered treatments, biofeedback, relaxation, psychological treatments, and psychological placebos were significantly more effective than waiting list with effect sizes ranging between SMD = 1.14 (95% confidence interval, 0.09 to 2.19) for long-term psychological placebos to SMD = 1.44 (95% confidence interval, 0.26 to 2.62) for short-term self-administered treatments. However, when all interventions were examined individually (ie, 1 node per intervention), none were significantly more effective compared with waiting list, mainly because of lack of statistical power. LIMITATIONS Because of our focus on pediatric migraine, only a small number of studies could be included. CONCLUSIONS Our findings reveal that components of nonpharmacological interventions are effective in treating pediatric migraine. Some effects have to be interpreted carefully because they are based on small studies. Future researchers should identify factors associated with individual responses in large, multicentered studies.
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Affiliation(s)
- Helen Koechlin
- Division of Clinical Psychology and Psychotherapy, University of Basel, Basel, Switzerland.,Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Harvard University, Boston, Massachusetts.,Contributed equally as co-first authors
| | - Joe Kossowsky
- Division of Clinical Psychology and Psychotherapy, University of Basel, Basel, Switzerland.,Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Harvard University, Boston, Massachusetts.,Contributed equally as co-first authors
| | - Thanh Lan Lam
- Institute of Medical Psychology, LMU Munich, Munich, Germany
| | | | - Jens Gaab
- Division of Clinical Psychology and Psychotherapy, University of Basel, Basel, Switzerland
| | - Charles B Berde
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Harvard University, Boston, Massachusetts
| | - Guido Schwarzer
- Institute of Medical Biometry and Statistics, University of Freiburg, Breisgau, Germany
| | - Klaus Linde
- Institute of General Practice and Health Services Research, School of Medicine, Technical University Munich, Munich, Germany
| | - Karin Meissner
- Institute of Medical Psychology, LMU Munich, Munich, Germany.,Division of Integrative Health Promotion, Coburg University of Applied Sciences, Coburg, Germany
| | - Cosima Locher
- Division of Clinical Psychology and Psychotherapy, University of Basel, Basel, Switzerland; .,Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Harvard University, Boston, Massachusetts.,Faculty of Health, University of Plymouth, Plymouth, United Kingdom; and.,Department of Consultation-Liaison Psychiatry and Psychosomatic Medicine, University Hospital Zurich, Zurich, Switzerland
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12
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Das R, Qubty W. Retrospective Observational Study on Riboflavin Prophylaxis in Child and Adolescent Migraine. Pediatr Neurol 2021; 114:5-8. [PMID: 33189027 DOI: 10.1016/j.pediatrneurol.2020.09.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Revised: 09/16/2020] [Accepted: 09/20/2020] [Indexed: 12/26/2022]
Abstract
BACKGROUND We evaluated the efficacy of riboflavin in pediatric migraineurs. METHODS A retrospective observational study was performed on 42 patients (aged six to 18 years) with migraine who were evaluated from January to December 2019 at Dell Children's Medical Center in Austin, Texas. Weight-based dosing of riboflavin was recommended for migraine prevention. Descriptive statistics were used to study the population demographics. Nonparametric tests were used for inferential statistics to study the effect of riboflavin on headache frequency, intensity, and duration. RESULTS Patients treated with riboflavin had a significant reduction in headache days per month (frequency) at the first follow-up visit at 2 to 4 months (T1) (11.07 ± 10.52 days) compared with the baseline T0 (21.90 ± 9.85 days); P < 0.001 in regard to the primary outcome in 42 patients (mean age, 13.38 ± 3.38). Mean headache intensity decreased from 8.85 (±6.41; T0) to 2.30 (±2.51; T1); P < 0.001 on a 0 to 10 scale. The headache duration also reduced significantly from 18.23 ± 17.07 hours (T0) to 10.18 ± 10.49 hours (T1); P = 0.001. There was a positive correlation between riboflavin efficacy and reduced use of acute medications (rs = 0.304; P = 0.05). Riboflavin was useful in reducing the frequency and intensity in two patients with new daily persistent headache. CONCLUSIONS Patients treated with riboflavin had a reduction in headache frequency, use of acute medications, and days of school missed. Riboflavin prophylaxis also reduced migraine intensity and duration. Riboflavin is recommended as a safe, inexpensive, and effective nutraceutical in the treatment of pediatric migraine.
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Affiliation(s)
- Rakhi Das
- Pediatric Headache Program, Department of Neurology, The University of Texas at Austin Dell Medical School, Austin, Texas
| | - William Qubty
- Pediatric Headache Program, Department of Neurology, The University of Texas at Austin Dell Medical School, Austin, Texas.
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13
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Stubberud A, Linde M, Brenner E, Heier M, Olsen A, Aamodt AH, Gravdahl GB, Tronvik E. Self‐administered biofeedback treatment app for pediatric migraine: A randomized pilot study. Brain Behav 2020. [PMCID: PMC7882181 DOI: 10.1002/brb3.1974] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
Objective To investigate the effect size, safety, and tolerability of a therapist‐independent biofeedback treatment app among adolescent with migraine. Materials and Methods This was a prospective, 3:1 ratio randomized, sham‐controlled, double‐blind, pilot study with 16 adolescents diagnosed with migraine randomized to eight weeks of biofeedback treatment (n = 12) or sham biofeedback (n = 4), carried out at two university hospitals in Norway. The prespecified and primary objective of the study was to observe changes in outcomes within the active treatment group. The sham control group was included in a minor ratio primarily to evaluate its feasibility. The primary outcome was change in headache frequency. A modified intention to treat analysis was performed, including participants completing at least seven biofeedback sessions in weeks 1–4 (n = 12 vs. n = 4) and weeks 5–8 (n = 7 vs. n = 2). Results Adherence was poor with 40% (136/336) of planned biofeedback sessions completed during weeks 5–8. Within the biofeedback group, a not statistically significant reduction in headache frequency was observed at weeks 1–4 (2.92 days/month, 95% CI −1.00 to 6.84, p = .145) and weeks 5–8 (1.85 days/month, 95% CI −2.01 to 5.72, p = .395). The biofeedback group experienced a median of one fewer headache days/month versus sham that did not reach significance (95% CI −4.0 to 9.0, p = .760). Conclusions We observed a small reduction in headache frequency in the active treatment group. Findings were likely undermined by low adherence and underpowered analyses but indicate that a therapist‐independent biofeedback treatment app has the potential to be an effective, tolerable, and inexpensive treatment option.
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Affiliation(s)
- Anker Stubberud
- Department of Neuromedicine and Movement ScienceNTNU Norwegian University of Science and TechnologyTrondheimNorway
| | - Mattias Linde
- Department of Neuromedicine and Movement ScienceNTNU Norwegian University of Science and TechnologyTrondheimNorway
- Norwegian Advisory Unit on Headaches, Department of NeurologySt. Olavs HospitalTrondheimNorway
| | - Eiliv Brenner
- Department of Neuromedicine and Movement ScienceNTNU Norwegian University of Science and TechnologyTrondheimNorway
- Norwegian Advisory Unit on Headaches, Department of NeurologySt. Olavs HospitalTrondheimNorway
| | - Martin Heier
- Department of Clinical Neuroscience for ChildrenOslo University HospitalOsloNorway
| | - Alexander Olsen
- Department of PsychologyNTNU Norwegian University of Science and TechnologyTrondheimNorway
- Department of Physical Medicine and RehabilitationSt. Olavs HospitalTrondheimNorway
| | | | - Gøril B. Gravdahl
- Department of Neuromedicine and Movement ScienceNTNU Norwegian University of Science and TechnologyTrondheimNorway
- Norwegian Advisory Unit on Headaches, Department of NeurologySt. Olavs HospitalTrondheimNorway
| | - Erling Tronvik
- Department of Neuromedicine and Movement ScienceNTNU Norwegian University of Science and TechnologyTrondheimNorway
- Norwegian Advisory Unit on Headaches, Department of NeurologySt. Olavs HospitalTrondheimNorway
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14
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Locher C, Kossowsky J, Koechlin H, Lam TL, Barthel J, Berde CB, Gaab J, Schwarzer G, Linde K, Meissner K. Efficacy, Safety, and Acceptability of Pharmacologic Treatments for Pediatric Migraine Prophylaxis: A Systematic Review and Network Meta-analysis. JAMA Pediatr 2020; 174:341-349. [PMID: 32040139 PMCID: PMC7042942 DOI: 10.1001/jamapediatrics.2019.5856] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
IMPORTANCE Migraine is one of the most common neurologic disorders in children and adolescents. However, a quantitative comparison of multiple preventive pharmacologic treatments in the pediatric population is lacking. OBJECTIVE To examine whether prophylactic pharmacologic treatments are more effective than placebo and whether there are differences between drugs regarding efficacy, safety, and acceptability. DATA SOURCES Systematic review and network meta-analysis of studies in MEDLINE, Cochrane, Embase, and PsycINFO published through July 2, 2018. STUDY SELECTION Randomized clinical trials of prophylactic pharmacologic treatments in children and adolescents diagnosed as having episodic migraine were included. Abstract, title, and full-text screening were conducted independently by 4 reviewers. DATA EXTRACTION AND SYNTHESIS Data extraction was conducted according to Preferred Reporting Items for Systematic Reviews and Meta-Analysis network meta-analysis guidelines. Quality was assessed with the Cochrane Risk of Bias tool. Effect sizes, calculated as standardized mean differences for primary outcomes and risk ratios for discontinuation rates, were assessed in a random-effects model. MAIN OUTCOMES AND MEASURES Primary outcomes were efficacy (ie, migraine frequency, number of migraine days, number of headache days, headache frequency, or headache index), safety (ie, treatment discontinuation owing to adverse events), and acceptability (ie, treatment discontinuation for any reason). RESULTS Twenty-three studies (2217 patients) were eligible for inclusion. Prophylactic pharmacologic treatments included antiepileptics, antidepressants, calcium channel blockers, antihypertensive agents, and food supplements. In the short term (<5 months), propranolol (standard mean difference, 0.60; 95% CI, 0.03-1.17) and topiramate (standard mean difference, 0.59; 95% CI, 0.03-1.15) were significantly more effective than placebo. However, the 95% prediction intervals for these medications contained the null effect. No significant long-term effects for migraine prophylaxis relative to placebo were found for any intervention. CONCLUSIONS AND RELEVANCE Prophylactic pharmacologic treatments have little evidence supporting efficacy in pediatric migraine. Future research could (1) identify factors associated with individual responses to pharmacologic prophylaxis, (2) analyze fluctuations of migraine attack frequency over time and determine the most clinically relevant length of probable prophylactic treatment, and (3) identify nonpharmacologic targets for migraine prophylaxis.
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Affiliation(s)
- Cosima Locher
- School of Psychology, University of Plymouth, Plymouth, England,Division of Clinical Psychology and Psychotherapy, University of Basel, Basel, Switzerland,Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Joe Kossowsky
- Division of Clinical Psychology and Psychotherapy, University of Basel, Basel, Switzerland,Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Helen Koechlin
- Division of Clinical Psychology and Psychotherapy, University of Basel, Basel, Switzerland,Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Thanh Lan Lam
- Institute of Medical Psychology, Medical Faculty, LMU Munich, Munich, Germany
| | - Johannes Barthel
- Institute of Medical Psychology, Medical Faculty, LMU Munich, Munich, Germany
| | - Charles B Berde
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Jens Gaab
- Division of Clinical Psychology and Psychotherapy, University of Basel, Basel, Switzerland
| | | | - Klaus Linde
- School of Medicine, Institute of General Practice and Health Services Research, Technical University Munich, Munich, Germany
| | - Karin Meissner
- Institute of Medical Psychology, Medical Faculty, LMU Munich, Munich, Germany,Division of Integrative Health Promotion, Coburg University of Applied Sciences, Coburg, Germany
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15
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Winner PK, Kabbouche M, Yonker M, Wangsadipura V, Lum A, Brin MF. A Randomized Trial to Evaluate OnabotulinumtoxinA for Prevention of Headaches in Adolescents With Chronic Migraine. Headache 2020; 60:564-575. [PMID: 32037549 PMCID: PMC7065250 DOI: 10.1111/head.13754] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/02/2020] [Indexed: 01/13/2023]
Abstract
OBJECTIVE As a post-approval commitment, this dose-ranging study was undertaken to evaluate efficacy and safety of onabotulinumtoxinA in adolescents. BACKGROUND In adolescents, migraine is often undiagnosed or misdiagnosed and can present unique management challenges. OnabotulinumtoxinA was approved for prevention of chronic migraine (CM) in adults in 2010. METHODS This multicenter, double-blind, parallel-group, randomized trial assessed a single treatment of onabotulinumtoxinA (155 U or 74 U) vs placebo (intramuscular saline) administered via the recommended fixed-dose fixed site paradigm in adolescents with CM aged 12 to <18 years. The primary efficacy measure was change in frequency of headache days from baseline at week 12; other measures included change in frequency of headache days at weeks 4 and 8 and change in frequency of severe headache days. Safety and tolerability were assessed. RESULTS Of 125 randomized patients (onabotulinumtoxinA 155 U, n = 45; onabotulinumtoxinA 74 U, n = 43; placebo, n = 37), all were included in the primary efficacy analysis, and 115 (92.0%) completed the study. Lack of efficacy was the primary reason for discontinuing (n = 4; 3.2%); no patients discontinued because of adverse events. All treatments reduced frequency of headache days at week 12, with no significant differences between treatments. The mean (95% confidence interval) changes from baseline in the frequency of headache days during the 28-day period ending at week 12 (primary endpoint) were -6.3 (-8.5, -4.2), -6.4 (-8.8, -4.0), and -6.8 (-9.6, -4.1) days in the onabotulinumtoxinA 155 U, onabotulinumtoxinA 74 U, and placebo groups, respectively (P ≥ .474). All treatments reduced frequency of severe headache days and were well-tolerated; serious adverse events (n = 3) were considered unrelated to treatment and resolved without sequelae. The most commonly reported treatment-emergent adverse events were neck pain (n = 8), upper respiratory tract infection (n = 7), migraine, and nasopharyngitis (n = 5 each). CONCLUSION Although this study did not meet its efficacy endpoints, onabotulinumtoxinA was well tolerated in this adolescent population. Given previous data demonstrating the benefits of onabotulinumtoxinA in adults with CM, additional studies with design modifications, including adequate statistical power, to assess the efficacy of multiple treatment cycles of onabotulinumtoxinA for CM prevention in adolescents may be informative.
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Affiliation(s)
- Paul K. Winner
- Palm Beach Headache CenterPremiere Research Institute@Palm Beach NeurologyWest Palm BeachFLUSA
| | | | - Marcy Yonker
- University of Colorado School of Medicine/Children’s HospitalAuroraCOUSA
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16
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Stubberud A, Tronvik E, Olsen A, Gravdahl G, Linde M. Biofeedback Treatment App for Pediatric Migraine: Development and Usability Study. Headache 2020; 60:889-901. [DOI: 10.1111/head.13772] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Revised: 01/24/2020] [Accepted: 01/24/2020] [Indexed: 01/18/2023]
Affiliation(s)
- Anker Stubberud
- Department of Neuromedicine and Movement Science NTNU Norwegian University of Science and Technology Trondheim Norway
| | - Erling Tronvik
- Department of Neuromedicine and Movement Science NTNU Norwegian University of Science and Technology Trondheim Norway
- National Advisory Unit on Headaches Department of Neurology and Clinical Neurophysiology St. Olavs Hospital Trondheim Norway
| | - Alexander Olsen
- Department of Psychology NTNU Norwegian University of Science and Technology Trondheim Norway
- Department of Physical Medicine and Rehabilitation St. Olavs Hospital Trondheim Norway
| | - Gøril Gravdahl
- Department of Neuromedicine and Movement Science NTNU Norwegian University of Science and Technology Trondheim Norway
- National Advisory Unit on Headaches Department of Neurology and Clinical Neurophysiology St. Olavs Hospital Trondheim Norway
| | - Mattias Linde
- Department of Neuromedicine and Movement Science NTNU Norwegian University of Science and Technology Trondheim Norway
- National Advisory Unit on Headaches Department of Neurology and Clinical Neurophysiology St. Olavs Hospital Trondheim Norway
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17
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Wu X, Zhang Y, Lu M, Yu X, Ye X, Wang X, Shan P. The Efficacy and Safety of Topiramate in the Prevention of Pediatric Migraine: An Update Meta-Analysis. Front Pediatr 2020; 8:28. [PMID: 32175291 PMCID: PMC7056737 DOI: 10.3389/fped.2020.00028] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2019] [Accepted: 01/20/2020] [Indexed: 12/12/2022] Open
Abstract
Background: Migraine is the most common acute primary headache in children and adolescents. In 2014, topiramate became the first preventive drug for migraine, approved by the Food and Drug Administration (FDA) for adolescents. This meta-analysis was aimed to evaluate the efficacy and safety of topiramate in the prevention of pediatric migraine. Methods: We searched the PubMed, EMBASE, Cochrane Library, and Chinese National Knowledge Infrastructure (CNKI) databases up to June 2019 for eligible randomized controlled trials (RCTs). The primary outcomes were mean migraine days per month, ≥50% reduction rate, and Pediatric Migraine Disability Assessment Scale (PedMIDAS) scores. RevMan5.3 software was performed for statistical analysis. Results: Overall, 5 RCTs recruiting 531 patients (6-17 years of age) were included in the meta-analysis. The target dose of topiramate was 2 mg/kg (the maintenance phase was 12 weeks), 2-3 mg/kg, 50 mg/day, and 100 mg/day (maintaining for 16 weeks), respectively, in the included studies. Our results demonstrate that participants receiving topiramate had a significant advantage in remitting the monthly migraine days than those receiving placebo, with a mean difference (MD) of -0.78 (n = 531; 95% CI, -1.23 to -0.32; Z = 3.37; P = 0.0008). Topiramate could also reduce the mean PedMIDAS scores (n = 238; 95% CI, -16.53 to -0.49; Z = 2.43; P = 0.04). However, there was no significant difference in the percentage of patients experiencing a ≥50% reduction in monthly headache days between topiramate and placebo groups (n = 531; 95% CI, 0.94-1.77; Z = 1.58; P = 0.11). Topiramate was associated with higher rates of side effects such as weight decrease (n = 395; 95% CI, 2.73-22.98; Z = 3.81; P < 0.01) and paresthesia (n = 531; 95% CI, 3.05-13.18; Z = 4.94; P < 0.01). Conclusions: Topiramate can significantly decrease monthly headache days and migraine-related burden in migraine patients <18 years old. However, it failed to increase 50% response rate. Adverse events seem to be more frequent in topiramate-treated children.
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Affiliation(s)
- Xinwei Wu
- Department of Geriatrics, Qilu Hospital of Shandong University, Jinan, China
| | - Yan Zhang
- Department of Gastroenterology, Qilu Hospital of Shandong University, Jinan, China
| | - Mei Lu
- Department of Geriatrics, Qilu Hospital of Shandong University, Jinan, China
| | - Xiaolin Yu
- Department of Geriatrics, Qilu Hospital of Shandong University, Jinan, China
| | - Xiang Ye
- Department of Geriatrics, Qilu Hospital of Shandong University, Jinan, China
| | - Xingbang Wang
- Department of Geriatrics, Qilu Hospital of Shandong University, Jinan, China
| | - Peiyan Shan
- Department of Geriatrics, Qilu Hospital of Shandong University, Jinan, China
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18
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The "virtual lesion" approach to transcranial magnetic stimulation: studying the brain-behavioral relationships in experimental pain. Pain Rep 2019; 4:e760. [PMID: 31579852 PMCID: PMC6728008 DOI: 10.1097/pr9.0000000000000760] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2018] [Revised: 04/24/2019] [Accepted: 04/27/2019] [Indexed: 12/11/2022] Open
Abstract
Transcranial magnetic stimulation (TMS) can be used to create a temporary “virtual lesion” (VL) of a target cortical area, disrupting its function and associated behavior. Transcranial magnetic stimulation can therefore test the functional role of specific brain areas. This scoping review aims at investigating the current literature of the “online” TMS-evoked VL approach to studying brain–behavioral relationships during experimental pain in healthy subjects. Ovid-Medline, Embase, and Web of Science electronic databases were searched. Included studies tested different TMS-based VLs of various pain brain areas during continuous experimental pain or when time-locked to a noxious stimulus. Outcome measures assessed different pain measurements. Initial screening resulted in a total of 403 studies, of which 17 studies were included in the review. The VLs were directed to the prefrontal, primary and secondary somatosensory, primary motor, and parietal cortices through single/double/triple/sequence of five-TMS pulses or through repeated TMS during mechanical, electrical contact, radiant heat, or capsaicin-evoked noxious stimulation. Despite a wide variability among the VL protocols, outcome measures, and study designs, a behavioral VL effect (decrease or increase in pain responses) was achieved in the majority of the studies. However, such findings on the relationships between the modified brain activity and the manifested pain characteristics were often mixed. To conclude, TMS–elicited VLs during experimental pain empower our understanding of brain–behavior relationships at specific time points during pain processing. The mixed findings of these relationships call for an obligatory standard of all pain-related TMS protocols for clearly determining the magnitude and direction of TMS-induced behavioral effects.
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19
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Hall AL, Karvounides D, Gelfand AA, Mankin H, Kessel S, Corroo J, Malavolta CP, Pezzuto T, Chadehumbe M, Szperka CL. Improving the Patient Experience With Migraine Camp, a One-Day Group Intervention for Adolescents With Chronic Headache and Their Parents. Headache 2019; 59:1392-1400. [PMID: 31165479 DOI: 10.1111/head.13570] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/08/2019] [Indexed: 01/19/2023]
Abstract
Though chronic migraine is actually common in adolescents, living with constant headache can be isolating for both patients and their families. As an outgrowth of clinical care, we developed the Miles for Migraine Youth Camp, a recurring 1-day event for adolescents with chronic headache and their parents. Migraine Camp was developed to provide expanded headache education, teach coping strategies for living with chronic pain, and encourage development of a supportive community for adolescents living with chronic headache disorders and their families. The creation and curriculum of the Camps at the University of California San Francisco and Children's Hospital of Philadelphia are described in this manuscript, along with patient and caregiver feedback. Overall, feedback was positive. Teens reported feeling less isolated and more prepared to cope with headaches using new strategies. Both patients and caregivers consistently described benefit from connecting with others who experience similar challenges. The Migraine Camp teams at both institutions found it feasible to conduct the Camps 1-2 times per year using existing resources, but noted that to scale it to a more regular event additional administrative and/or volunteer support would be needed. In summary, the experience has been positive for patients, caregivers, and staff, and we hope that this manuscript can serve as a "how to" model for similar events at other institutions.
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Affiliation(s)
- Amanda L Hall
- Pediatric Headache Program, Division of Neurology, Children's Hospital of Philadelphia, Philadelphia, PA, USA.,Yale New Haven Health/Connecticut Medical Group, New Haven, CT, USA
| | - Dina Karvounides
- Pediatric Headache Program, Division of Neurology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Amy A Gelfand
- Department of Neurology, UCSF Child & Adolescent Headache Program, San Francisco, CA, USA
| | - Haley Mankin
- School of Social Policy and Practice, University of Pennsylvania, Philadelphia, PA, USA
| | | | - Janet Corroo
- Department of Neurology, UCSF Child & Adolescent Headache Program, San Francisco, CA, USA.,Miles for Migraine, Lafayette Hill, PA, USA
| | - Carrie P Malavolta
- Pediatric Headache Program, Division of Neurology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Tara Pezzuto
- Nemours Neurology Headache Program, Alfred I. Dupont Hospital for Children, Wilmington, DE, USA
| | - Madeline Chadehumbe
- Pediatric Headache Program, Division of Neurology, Children's Hospital of Philadelphia, Philadelphia, PA, USA.,Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Christina L Szperka
- Pediatric Headache Program, Division of Neurology, Children's Hospital of Philadelphia, Philadelphia, PA, USA.,Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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20
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Montazerlotfelahi H, Amanat M, Tavasoli AR, Agah E, Zamani GR, Sander JW, Badv RS, Mohammadi M, Dehghani M, Heidari M, Hosseini SA, Salehi M, Ashrafi MR. Levetiracetam for prophylactic treatment of pediatric migraine: A randomized double-blind placebo-controlled trial. Cephalalgia 2019; 39:1509-1517. [PMID: 31154809 DOI: 10.1177/0333102419851814] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
INTRODUCTION Few drugs are available for migraine prophylaxis in children. Levetiracetam is a broad-spectrum anti-seizure drug that has been suggested to be effective in reducing adult migraine episodes. We assessed the safety and efficacy of levetiracetam in the prevention of pediatric migraine. METHODS A randomized double-blind placebo-controlled trial was performed. Eligible participants were aged 4-17 years old with at least four migrainous episodes monthly or had severe disabling or intolerable episodes. Primary endpoints were the mean changes in monthly frequency and intensity of headaches from the baseline phase to the last month of the double-blind phase. Safety endpoint was the adverse effects reported. RESULTS Sixty-one participants (31 taking levetiracetam and 30 taking placebo) completed the study. All had a significant reduction in frequency and intensity of episodes that was significantly greater in the levetiracetam arm. Sixty eight percent of individuals in the treatment group reported more than 50% reduction of episodes at the end of the trial compared with 30% in the placebo group (p-value: 0.007). Irritability, day-time sedation, and mild tic were reported. CONCLUSION Levetiracetam may be useful in migraine prevention and may decrease migraine episodes and severity. TRIAL REGISTRATION The study is prospectively registered with Iranian Registry of Clinical Trials; IRCT.ir, number IRCT2017021632603N1.
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Affiliation(s)
- Hadi Montazerlotfelahi
- Pediatrics Center of Excellence, Department of Pediatric Neurology, Imam Ali Hospital, Alborz University of Medical Sciences, Karaj, Iran
| | - Man Amanat
- Faculty of Medicine, Students' Scientific Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Ali Reza Tavasoli
- Pediatrics Center of Excellence, Department of Pediatric Neurology, Children's Medical Center, Growth and Development Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Elmira Agah
- Faculty of Medicine, Students' Scientific Research Center, Tehran University of Medical Sciences, Tehran, Iran.,NeuroImmunology Research Association (NIRA), Universal Scientific Education and Research Network (USERN), Tehran, Iran
| | - Gholam Reza Zamani
- Pediatrics Center of Excellence, Department of Pediatric Neurology, Children's Medical Center, Growth and Development Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Josemir W Sander
- Stichting Epilepsie Instellingen Nederland (SEIN), Heemstede, the Netherlands.,NIHR University College London Hospitals Biomedical Research Centre, UCL Queen Square Institute of Neurology, London, UK.,Chalfont Centre for Epilepsy, Chalfont St Peter, UK
| | - Reza Shervin Badv
- Pediatrics Center of Excellence, Department of Pediatric Neurology, Children's Medical Center, Growth and Development Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Mahmoud Mohammadi
- Pediatrics Center of Excellence, Department of Pediatric Neurology, Children's Medical Center, Growth and Development Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Mahdieh Dehghani
- Department of Oral and Maxillofacial Radiology, Faculty of Dentistry, Shahid Sadoughi University of Medical Sciences, Yazd, Iran
| | - Morteza Heidari
- Pediatrics Center of Excellence, Department of Pediatric Neurology, Children's Medical Center, Growth and Development Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Seyed Ahmad Hosseini
- Department of Pediatric Neurology, Golestan University of Medical Sciences, Golestan, Iran
| | - Mona Salehi
- Faculty of Medicine, Students' Scientific Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Mahmoud Reza Ashrafi
- Pediatrics Center of Excellence, Department of Pediatric Neurology, Children's Medical Center, Growth and Development Research Center, Tehran University of Medical Sciences, Tehran, Iran
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Palermo TM, Kashikar-Zuck S, Friedrichsdorf SJ, Powers SW. Special considerations in conducting clinical trials of chronic pain management interventions in children and adolescents and their families. Pain Rep 2019; 4:e649. [PMID: 31583334 PMCID: PMC6749908 DOI: 10.1097/pr9.0000000000000649] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2017] [Revised: 02/21/2018] [Accepted: 03/03/2018] [Indexed: 12/19/2022] Open
Abstract
INTRODUCTION Disabling chronic pain is a common experience for children and adolescents. However, the evidence base for chronic pain interventions for youth is extremely limited, which has hindered the development of evidence-based practice guidelines for most pediatric chronic pain conditions. OBJECTIVES To review and provide recommendations on clinical trial design and evaluation in children and adolescents with chronic pain. METHODS In this article, we summarize key issues and provide recommendations for addressing them in clinical trials of chronic pain interventions in children and adolescents and their families. RESULTS To stimulate high-quality trials of pediatric chronic pain management interventions, attention to key issues including sample characterization, trial design and treatment administration, outcome measurement, and the ethics of intervening with children and adolescents, as opposed to adults with chronic pain, is needed. CONCLUSION Future research to develop interventions to reduce or prevent childhood chronic pain is an important priority area, and requires special considerations in implementation and evaluation in clinical trials.
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Affiliation(s)
- Tonya M. Palermo
- Center for Child Health, Behavior, and Development, Seattle Children's Research Institute, Seattle, WA, USA
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, WA, USA
| | - Susmita Kashikar-Zuck
- Division of Behavioral Medicine and Clinical Psychology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Stefan J. Friedrichsdorf
- Department of Pain Medicine, Palliative Care and Integrative Medicine, Children's Hospitals and Clinics of Minnesota, Minneapolis, MN, USA
| | - Scott W. Powers
- Division of Behavioral Medicine and Clinical Psychology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
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Moscano F, Guiducci M, Maltoni L, Striano P, Ledda MG, Zoroddu F, Raucci U, Villa MP, Parisi P. An observational study of fixed-dose Tanacetum parthenium nutraceutical preparation for prophylaxis of pediatric headache. Ital J Pediatr 2019; 45:36. [PMID: 30871574 PMCID: PMC6419324 DOI: 10.1186/s13052-019-0624-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2019] [Accepted: 02/25/2019] [Indexed: 12/23/2022] Open
Abstract
Background Migraine is one of the most prevalent chronic pain manifestations of childhood. Despite the multitude of available treatments, parents are often concerned about chronic therapies and pediatricians have insufficient confidence in prescribing prophylactic drugs. Therefore, there is now growing interest for natural supplements used to control recurrent migraine headaches. Such approach may increase acceptance and adherence to long-term prophylaxis therapy in children. Methods This is an observational multicenter study performed in children (n = 91) with migraine, with (MO) or without aura (MA), or tension-type headache (TTH). A fixed-dose Andrographis paniculata, CoQ10, riboflavin, and magnesium, was administered for 16 weeks. Patients were evaluated at baseline (T0), at week 8 (T1) and at the end of treatment at week 16 (T2). A follow-up period occurred at week 20 (T3) and week 32 (T4). Results The herbal supplement significantly reduced the frequency of headaches in TTH patients during treatment period (T0: 11.97 + 1.92 vs T2: 5.13 + 1.93; p < 0.001) and the efficacy was maintained after 16 weeks of treatment withdrawal (T4: 4.46 + 1.75; p < 0.001 vs T0). The frequency of migraine attacks was also reduced in the MO group during treatment (T0: 9.70 + 0.96 vs T2: 4.03 + 0.75; p < 0.01) and after withdrawal (T4: 2.96 + 0.65; p < 0.01 vs T0). Conversely, MA patients showed reduction in migraine’s frequency during treatment (T0: 8.74 + 1.91 vs T2: 3.78 + 2.02; p < 0.01) but not at the end of the study (T4: 5.57 + 3.31; p > 0.05 vs T0). TTH patients did not report significant improvement of pain intensity. A significant effect was observed in the MO group during treatment (T0: 3.06 + 0.11 vs T2: 2.14 + 0.19; p < 0.001) and after treatment withdrawal (T4: 2.20 + 0.21; p < 0.001 vs T0). Likewise, MA group showed a significant treatment effect (T0: 2.57 + 0.20 vs T2: 0.86 + 0.45; p < 0.001) and the efficacy persisted at the end of the study (T4: 1.00 + 0.58; p < 0.001 vs T0). Conclusion This fixed-dose Tanacetum parthenium preparation improved headache frequency and pain intensity in children affected by TTH. Despite the main limits, this study supports the use of nutraceutical in pediatric headache/migraine.
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Affiliation(s)
- Filomena Moscano
- Child & Adolescent Neuropsychiatry, Hospital S. Orsola Malpighi, Bologna University, Bologna, Italy
| | - Michela Guiducci
- Child Neurology, Pediatric Headache & Sleep Disorders Centre, Chair of Pediatrics, NESMOS Department, Faculty of Medicine and Psychology, Sapienza University, Via Di Grottarossa, 1035-1039, 00189, Rome, Italy
| | - Lucia Maltoni
- Child & Adolescent Neuropsychiatry, Hospital S. Orsola Malpighi, Bologna University, Bologna, Italy
| | - Pasquale Striano
- Paediatric Neurology and Muscular Diseases Unit, Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genoa, 'G. Gaslini' Institute, Genoa, Italy
| | - Maria Giuseppina Ledda
- Child & Adolescent Neuropsychiatry Unit, "Antonio Cao" Paediatric Hospital, "G.Brotzu" Hospital, Cagliari, Italy
| | - Francesco Zoroddu
- Pediatric Headache Center, Neurology Unit Hospital, University of Sassari, Sassari, Italy
| | - Umberto Raucci
- Pediatric Emergency Department, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Maria Pia Villa
- Child Neurology, Pediatric Headache & Sleep Disorders Centre, Chair of Pediatrics, NESMOS Department, Faculty of Medicine and Psychology, Sapienza University, Via Di Grottarossa, 1035-1039, 00189, Rome, Italy
| | - Pasquale Parisi
- Child Neurology, Pediatric Headache & Sleep Disorders Centre, Chair of Pediatrics, NESMOS Department, Faculty of Medicine and Psychology, Sapienza University, Via Di Grottarossa, 1035-1039, 00189, Rome, Italy.
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Kovalchuk PV, Katilov OV, Panenko SO. Modern approaches to diagnostics and treatment of migraine in children. PAIN MEDICINE 2019. [DOI: 10.31636/pmjua.v3i4.2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
This article reviews modern approaches to diagnostics and treatment of a very common and simultaneously underestimated and often maltreated disorder in children. It is fallacious management of migraine masked behind the diagnoses such as autonomic vessel dysfunction and vascular headache here in Ukraine. This is a tremendous problem and it should be solved with appropriate information spread across the medical community.
Up-to-date classification according to the International Headache Society, diagnostic criteria, differential diagnosis, investigation and treatment strategies are presented in the article. All supported data are com-pliant with guidelines of developed countries with evidence-based medicine (US, Canada, Great Britain, Japan, Australia, New Zealand) enhanced with new trials and approved methods. Migraine management is a rapidly evolving concept, where major changes were done during recent years (transcranial Deep Brain Stimulation, vagus stimulation, CGRP-receptor mono-clonal antibodies).
Considering disorder incidence and its impact on life quality and the existence of options for alleviating symptoms, this information is important for physicians who work with children, especially for general practitioners, pediatrics, pediatric and adult neurologists.
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24
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Kroon Van Diest AM, Powers SW. Cognitive Behavioral Therapy for Pediatric Headache and Migraine: Why to Prescribe and What New Research Is Critical for Advancing Integrated Biobehavioral Care. Headache 2018; 59:289-297. [PMID: 30444269 DOI: 10.1111/head.13438] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/16/2018] [Indexed: 12/30/2022]
Abstract
PURPOSE OF REVIEW To highlight current evidence supporting the prescription of cognitive behavioral therapy (CBT) as part of first-line preventive treatment for children and adolescents with headache and discuss a research strategy aimed at: (1) understanding how and why CBT works, and (2) developing effective and efficient approaches for integrating CBT into headache specialty, neurology, and primary care settings. RECENT FINDINGS Although preventive medications for pediatric headache and migraine are commonly prescribed, recent meta-analyses and an NIH-funded, multi-center clinical trial suggests that the effect of pill-taking therapies may be mostly due to a placebo effect. These findings have led to greater consideration of prescription of non-pharmacological therapies as first-line interventions (either alone or in combination with pill-based therapy). A literature that extends back to the 1980s and includes recent clinical trials and meta-analyses demonstrates that CBT decreases headache frequency and related disability in youth with headache and migraine and has a favorable benefit to risk profile with almost no negative side effects. SUMMARY CBT has been repeatedly demonstrated as effective in treating pediatric headache and migraine. As such, it should be considered as part of first-line preventive treatment for pediatric headache (either alone or in combination with a pill-based therapy). We need to better understand how this therapy works and what makes it distinct (if anything) from the placebo effect. What we need to achieve is empirical support for efficient access to this evidence-based treatment and clarity on how to match the intensity of non-pharmacological intervention to the needs of our patients at the time they present for care.
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Affiliation(s)
- Ashley M Kroon Van Diest
- Department of Pediatric Psychology and Neuropsychology, Nationwide Children's Hospital, Columbus, OH, USA.,Department of Pediatrics, The Ohio State University, Columbus, OH, USA
| | - Scott W Powers
- Division of Behavioral Medicine and Clinical Psychology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA.,Headache Center, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
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25
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Szperka CL, VanderPluym J, Orr SL, Oakley CB, Qubty W, Patniyot I, Lagman-Bartolome AM, Morris C, Gautreaux J, Victorio MC, Hagler S, Narula S, Candee MS, Cleves-Bayon C, Rao R, Fryer RH, Bicknese AR, Yonker M, Hershey AD, Powers SW, Goadsby PJ, Gelfand AA. Recommendations on the Use of Anti-CGRP Monoclonal Antibodies in Children and Adolescents. Headache 2018; 58:1658-1669. [PMID: 30324723 DOI: 10.1111/head.13414] [Citation(s) in RCA: 50] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/29/2018] [Indexed: 12/14/2022]
Affiliation(s)
- Christina L Szperka
- Division of Neurology, Children's Hospital of Philadelphia & Departments of Neurology & Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | | | - Serena L Orr
- Cincinnati Children's Hospital Medical Center and Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | | | | | | | | | - Cynthia Morris
- Saint Louis University School of Medicine, St. Louis, MO, USA
| | - Jessica Gautreaux
- Lousiana State University Health Science Center and Children's Hospital New Orleans, New Orleans, LA, USA
| | | | | | - Sona Narula
- Division of Neurology, Children's Hospital of Philadelphia & Departments of Neurology & Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Meghan S Candee
- University of Utah, Primary Children's Hospital, Salt Lake City, UT, USA
| | | | - Rashmi Rao
- Lousiana State University Health Science Center and Children's Hospital New Orleans, New Orleans, LA, USA
| | | | - Alma R Bicknese
- Feinberg School of Medicine at Northwestern University & Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | | | - Andrew D Hershey
- Cincinnati Children's Hospital Medical Center and Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Scott W Powers
- Cincinnati Children's Hospital Medical Center and Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
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Huang P, Kuo PH, Lee MT, Chiou LC, Fan PC. Age-Dependent Anti-migraine Effects of Valproic Acid and Topiramate in Rats. Front Pharmacol 2018; 9:1095. [PMID: 30319425 PMCID: PMC6167431 DOI: 10.3389/fphar.2018.01095] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2018] [Accepted: 09/07/2018] [Indexed: 01/18/2023] Open
Abstract
Background: Valproic acid (VPA) and topiramate (TPM), initially developed as antiepileptics, are approved for migraine prophylaxis in adults but not children. The differences in their antimigraine mechanism(s) by age remain unclear. Methods: A migraine model induced by intra-cisternal (i.c.) capsaicin instillation in pediatric (4–5 weeks) and adult (8–9 weeks) rats was pretreated with VPA (30, 100 mg/kg) or TPM (10, 30, 100 mg/kg). Noxious meningeal stimulation by the irritant capsaicin triggered trigeminovascular system (TGVS) activation mimicking migraine condition, which were assessed peripherally by the depletion of calcitonin gene-related peptide (CGRP) in sensory nerve fibers of the dura mater, the increased CGRP immunoreactivity at trigeminal ganglia (TG) and centrally by the number of c-Fos-immunoreactive (c-Fos-ir) neurons in the trigeminocervical complex (TCC). Peripherally, CGRP released from dural sensory nerve terminals of TG triggered pain signal transmission in the primary afferent of trigeminal nerve, which in turn caused central sensitization of the TGVS due to TCC activation and hence contributed to migraine. Results: In the VPA-treated group, the central responsiveness expressed by reducing the number of c-Fos-ir neurons, which had been increased by i.c. capsaicin, was significant in pediatric, but not adult, rats. Inversely, VPA was effective in peripheral inhibition of elevated CGRP immunoreactivity in the TG and CGRP depletion in the dura mater of adult, but not pediatric, rats. In TPM group, the central responsiveness was significant in both adult and pediatric groups. Peripherally, TPM significantly inhibited capsaicin-induced CGRP expression of TG in adult, but not pediatric, rats. Interestingly, the capsaicin-induced depletion of CGRP in dura was significantly rescued by TPM at high doses in adults, but at low dose in pediatric group. Conclusion: These results suggest VPA exerted peripheral inhibition in adult, but central suppression in pediatric migraine-rats. In contrast, TPM involves both central and peripheral inhibition of migraine with an optimal therapeutic window in both ages. These findings may clarify the age-dependent anti-migraine mechanism of VPA and TPM, which may guide the development of new pediatric anti-migraine drugs in the future.
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Affiliation(s)
- Pokai Huang
- Department of Pediatrics, E-da Dachang Hospital, Kaohsiung, Taiwan
| | - Ping-Hung Kuo
- Department of Internal Medicine, National Taiwan University Hospital, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Ming Tatt Lee
- Graduate Institute of Brain and Mind Sciences, College of Medicine, National Taiwan University, Taipei, Taiwan.,Graduate Institute of Pharmacology, College of Medicine, National Taiwan University, Taipei, Taiwan.,Faculty of Pharmaceutical Sciences, UCSI University, Kuala Lumpur, Malaysia
| | - Lih-Chu Chiou
- Graduate Institute of Brain and Mind Sciences, College of Medicine, National Taiwan University, Taipei, Taiwan.,Graduate Institute of Pharmacology, College of Medicine, National Taiwan University, Taipei, Taiwan.,Graduate Institute of Acupuncture Science, China Medical University, Taichung, Taiwan
| | - Pi-Chuan Fan
- Department of Pediatrics, National Taiwan University Hospital, College of Medicine, National Taiwan University, Taipei, Taiwan
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27
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Shah S, Calderon MD, Wu WD, Grant J, Rinehart J. Onabotulinumtoxin A (BOTOX®) for ProphylaCTIC Treatment of Pediatric Migraine: A Retrospective Longitudinal Analysis. J Child Neurol 2018; 33:580-586. [PMID: 29877131 DOI: 10.1177/0883073818776142] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND The use of onabotulinumtoxin A in the pediatric population has not been evaluated for chronic migraine in a longitudinal study. This retrospective study sought to determine the efficacy and safety of onabotulinumtoxin A in prophylactic treatment of chronic migraine in the pediatric population. METHODS The authors retrospectively evaluated pediatric patients who had been treated with onabotulinumtoxin A in the outpatient pain clinic for chronic migraine. Demographic data and pre- and posttreatment migraine days (frequency), pain scores (intensity), and duration of migraine episodes were collected from patient records. RESULTS Ten patients were included. Median pretreatment to posttreatment headache frequency was 15.5 [8, 29.5] to 4 [2, 10] days/month ( P < .0001), durations were 8 [0, 24] to 1 [0, 7] hours ( P = .025), and intensity was 6 [4, 8] to 4 [2, 5] ( P = .0063). No serious adverse events were reported. CONCLUSIONS This review over a 5-year longitudinal period demonstrates statistically significant improvement from baseline.
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Affiliation(s)
- Shalini Shah
- 1 Department of Anesthesiology & Perioperative Care, University of California, Irvine, Orange, CA, USA
| | - Michael-David Calderon
- 1 Department of Anesthesiology & Perioperative Care, University of California, Irvine, Orange, CA, USA
| | - Wei Der Wu
- 1 Department of Anesthesiology & Perioperative Care, University of California, Irvine, Orange, CA, USA
| | - Jihan Grant
- 1 Department of Anesthesiology & Perioperative Care, University of California, Irvine, Orange, CA, USA
| | - Joseph Rinehart
- 1 Department of Anesthesiology & Perioperative Care, University of California, Irvine, Orange, CA, USA
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28
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Orr SL, Kabbouche MA, O’Brien HL, Kacperski J, Powers SW, Hershey AD. Paediatric migraine: evidence-based management and future directions. Nat Rev Neurol 2018; 14:515-527. [DOI: 10.1038/s41582-018-0042-7] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
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29
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Affiliation(s)
| | - Christina L. Szperka
- Division of Neurology, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- Department of Neurology, University of Pennsylvania, Perelman School of Medicine, Philadelphia
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30
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Orr SL. The Evidence for the Role of Nutraceuticals in the Management of Pediatric Migraine: a Review. Curr Pain Headache Rep 2018; 22:37. [PMID: 29619575 DOI: 10.1007/s11916-018-0692-6] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
PURPOSE OF REVIEW Nutraceuticals are a form of complementary and alternative medicine that is commonly used by children and adolescents with migraine. In this review, observational studies, randomized controlled trials, systematic reviews, and meta-analyses on the efficacy and safety of single compound nutraceuticals for the management of migraine in children and adolescents were identified through a literature search of MEDLINE, Embase, and EBM Reviews-Cochrane Central Register of Controlled Trials. RECENT FINDINGS Twenty-one studies were reviewed, of which 11 were observational studies, 7 were randomized controlled trials, and 3 were systematic reviews. Six different nutraceuticals were included in the review: vitamin D, riboflavin, coenzyme Q10, magnesium, butterbur, and polyunsaturated fatty acids. All but three of the studies assessed the role of nutraceuticals in migraine prevention, while three studies evaluated the role of intravenous magnesium for acute migraine management. Overall, the quality and size of the studies were limited. Due to low quality evidence and limited studies, no definite conclusions can be drawn on the efficacy of nutraceuticals for the treatment of pediatric migraine. Future studies are warranted in order to establish evidence upon which to define the role of nutraceuticals in this patient population.
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Affiliation(s)
- Serena L Orr
- Division of Neurology, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH, 45229, USA.
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31
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Hawks M, Mounsey A. PURL: Treating migraines: It's different for kids. THE JOURNAL OF FAMILY PRACTICE 2018; 67:238-241. [PMID: 29614145 PMCID: PMC5898652] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
Certain medications used for migraine prevention in adults do not perform the same way in children and adolescents and can actually cause harm.
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Affiliation(s)
- Matthew Hawks
- Nellis AFB Family Medicine Residency, Las Vegas, Nevada, USA
| | - Anne Mounsey
- Department of Family Medicine, The University of North Carolina, Chapel Hill, USA
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32
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Karlsson Lind L, Wide K, Wettermark B, von Euler M. Utilization of Antiepileptic Medicines in Swedish Children and Adolescents with Different Diagnoses. Basic Clin Pharmacol Toxicol 2018; 123:94-100. [DOI: 10.1111/bcpt.12981] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2017] [Accepted: 01/31/2018] [Indexed: 01/18/2023]
Affiliation(s)
- Linnéa Karlsson Lind
- Department of Clinical Science and Education; Södersjukhuset; Karolinska Institutet; Stockholm Sweden
- The Health and Medical Care Administration; Stockholm County Council; Stockholm Sweden
| | - Katarina Wide
- Department of Pediatrics; CLINTEC; Karolinska Institutet; Stockholm Sweden
| | - Björn Wettermark
- The Health and Medical Care Administration; Stockholm County Council; Stockholm Sweden
- Centre for Pharmacoepidemiology (CPE); Department of Medicine; Clinical Epidemiology Unit Solna; Karolinska Institutet; Stockholm Sweden
| | - Mia von Euler
- Department of Clinical Science and Education; Södersjukhuset; Karolinska Institutet; Stockholm Sweden
- Division of Clinical Pharmacology; Karolinska University Hospital Solna; Stockholm Sweden
- Karolinska Institutet Stroke Research Network at Södersjukhuset; Stockholm Sweden
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33
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Balottin L, Mannarini S, Candeloro D, Mita A, Chiappedi M, Balottin U. Rorschach Evaluation of Personality and Emotional Characteristics in Adolescents With Migraine Versus Epilepsy and Controls. Front Neurol 2018; 9:160. [PMID: 29615959 PMCID: PMC5869322 DOI: 10.3389/fneur.2018.00160] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2017] [Accepted: 03/05/2018] [Indexed: 01/24/2023] Open
Abstract
The literature examining primary headache, including migraine, in adolescents, has pointed out the key role played by a wide range of psychiatric disorders in reducing the patients’ quality of life. Moreover, pioneering studies showed that preexisting personality characteristics, specific emotion regulation styles and psychological-psychiatric difficulties are likely to increase the risk of the onset, maintenance, and outcome of headache. Still personality issues in migraine have been poorly studied, in particular in children and adolescents. This study aims, therefore, to investigate the specific characteristics of personality, and in particular emotion regulation and coping strategies, in adolescent with migraine, comparing them with age-matched patients with idiopathic epilepsy and healthy adolescents. 52 adolescents (age: 11–17) were assessed using a multi-method test battery, which included a self-report questionnaire (the youth self-report), a proxy-report (child behavior checklist) along with a projective personality test, the Rorschach Test, administered and scored according to the Exner comprehensive system. The results showed specific personality characteristics in adolescents with migraine, revealing a marked difficulty in modulating and regulating affections through thoughts and reflections, resorting instead to impulsive acts and maladaptive coping strategies, thus revealing a vague and immature perception of reality. Differently from adolescents belonging to the general population, but similarly to patients with epilepsy, adolescents with migraine perceive a high situational stress, probably related to the condition of suffering from chronic disease. They have, therefore, a lower self-consideration and self-esteem along with a poorer insight regarding themselves as well as the relations with others. In line with previous findings, these preliminary results suggest the need for further research on ample samples, using also standardized projective test in order to better understand the pathogenesis of psychological difficulties in patients with migraine. As a clinical implication, the results seem to indicate that providing a psychological integrated approach can play a pivotal role in the assessment and treatment of adolescent with migraine, in order to improve the outcome and the quality of life of the young patients.
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Affiliation(s)
- Laura Balottin
- Interdepartmental Center for Family Research, Department of Philosophy, Sociology, Education, and Applied Psychology, Section of Applied Psychology, University of Padova, Padova, Italy
| | - Stefania Mannarini
- Interdepartmental Center for Family Research, Department of Philosophy, Sociology, Education, and Applied Psychology, Section of Applied Psychology, University of Padova, Padova, Italy
| | - Daniela Candeloro
- Child Neuropsychiatry Unit, Department of Brain and Behavioral Sciences, University of Pavia, Pavia, Italy
| | - Alda Mita
- Child Neuropsychiatry Unit, Department of Brain and Behavioral Sciences, University of Pavia, Pavia, Italy
| | - Matteo Chiappedi
- Child Neuropsychiatry Unit, IRCCS Mondino Foundation, Pavia, Italy
| | - Umberto Balottin
- Child Neuropsychiatry Unit, Department of Brain and Behavioral Sciences, University of Pavia, Pavia, Italy.,Child Neuropsychiatry Unit, IRCCS Mondino Foundation, Pavia, Italy
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34
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Galili E, Barzilai A, Shreberk‐Hassidim R, Merdler I, Caspi T, Astman N. Neuropsychiatric comorbidity among adolescents with psoriasis. Br J Dermatol 2018; 178:910-916. [DOI: 10.1111/bjd.16031] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/01/2017] [Indexed: 01/02/2023]
Affiliation(s)
- E. Galili
- Department of Dermatology Sheba Medical Center, Tel‐Hashomer Sackler Faculty of Medicine Tel Aviv University Tel Aviv Israel
- Medical Corps Israel Defense Force Ramat Gan Israel
| | - A. Barzilai
- Department of Dermatology Sheba Medical Center, Tel‐Hashomer Sackler Faculty of Medicine Tel Aviv University Tel Aviv Israel
| | - R. Shreberk‐Hassidim
- Department of Dermatology Hadassah‐Hebrew University Medical Center Jerusalem Israel
| | - I. Merdler
- Department of Internal Medicine “H” Tel‐Aviv Sourasky Medical Center Sackler Faculty of Medicine Tel Aviv University Tel Aviv Israel
| | - T. Caspi
- Medical Corps Israel Defense Force Ramat Gan Israel
| | - N. Astman
- Department of Dermatology Sheba Medical Center, Tel‐Hashomer Sackler Faculty of Medicine Tel Aviv University Tel Aviv Israel
- Medical Corps Israel Defense Force Ramat Gan Israel
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Abstract
Migraine is one of the most common neurologic conditions in pediatrics. It can be a significant stressor, causing absences from school and interruption of parents' work and family schedules. The mainstay of treatment remains educating patients about healthy lifestyle practices and the influences of sleep, stressors, and hydration on triggering migraine attacks. Psychological therapies such as biofeedback or cognitive-behavioral therapy may be beneficial in some patients, especially those with prominent psychological comorbidities. New advances in the pathophysiology of migraine and additional pediatric approval of abortive therapy with triptans have led to significant advances in the management of migraine in children. Some challenges to preventive therapy were recently noted with the negative results obtained in the Childhood and Adolescent Migraine Prevention Study, which compared prescription drugs to placebo. Inherent differences between adult and pediatric headaches, with shorter duration of pediatric migraine and prominent placebo effect, present recurring challenges for clinicians. [Pediatr Ann. 2018;47(2):e55-e60.].
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36
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Abstract
Sports-related concussion (SRC) is a common problem in youth sports. Concussion may occur after a forceful hit to the body or head, resulting in transient neuropathological changes that spontaneously resolve with relative rest and activity modification in most patients. Most SRCs are effectively managed by primary care physicians and sports medicine specialists. In some cases, symptoms may persist and the child and adolescent psychiatrist may be consulted. This article reviews important background information regarding SRC and highlights a variety of pharmacologic and nonpharmacologic treatment options that consultant psychiatrists should know.
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37
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Wilkinson D, Ade KK, Rogers LL, Attix DK, Kuchibhatla M, Slade MD, Smith LL, Poynter KP, Laskowitz DT, Freeman MC, Hoffer ME, Saper JR, Scott DL, Sakel M, Calhoun AH, Black RD. Preventing Episodic Migraine With Caloric Vestibular Stimulation: A Randomized Controlled Trial. Headache 2017; 57:1065-1087. [PMID: 28656612 DOI: 10.1111/head.13120] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2017] [Revised: 03/29/2017] [Accepted: 04/09/2017] [Indexed: 01/02/2023]
Abstract
OBJECTIVE To evaluate the safety and efficacy of a novel solid-state, caloric vestibular stimulation (CVS) device to provide adjuvant therapy for the prevention of episodic migraine in adult migraineurs. BACKGROUND Migraine causes significant disability in ∼12% of the world population. No current migraine preventive treatment provides full clinical relief, and many exhibit high rates of discontinuation due to adverse events. Thus, new therapeutic options are needed. CVS may be an effective and safe adjuvant-therapy for the prevention of episodic migraine. METHODS In a multicenter, parallel-arm, block-randomized, placebo-controlled clinical trial (clinicaltrials.gov: NCT01899040), subjects completed a 3-month treatment with the TNM™ device for CVS (refer to Fig. 2 for patient enrollment and allocation). The primary endpoint was the change in monthly migraine days from baseline to the third treatment month. Secondary endpoints were 50% responder rates, change in prescription analgesic usage and difference in total subjective headache-related pain scores. Device safety assessments included evaluation of any impact on mood, cognition, or balance. RESULTS Per-protocol, active-arm subjects showed immediate and continued steady declines in migraine frequency over the treatment period. After 3 months of treatment, active-arm subjects exhibited significantly fewer migraine days (-3.9 ± 0.6 from a baseline burden of 7.7 ± 0.5 migraine days). These improvements were significantly greater than those observed in control subjects (-1.1 ± 0.6 from a baseline burden = 6.9 ± 0.7 migraine days) and represented a therapeutic gain of -2.8 migraine days, CI = -0.9 to -4.7, P = .012. Active arm subjects also reported greater reductions in acute medication usage and monthly pain scores compared to controls. No adverse effects on mood, cognition, or balance were reported. Subjects completed the trial with an average rate of 90% treatment adherence. No serious or unexpected adverse events were recorded. The rate of expected adverse events was similar across the active and the placebo groups, and evaluation confirmed that subject blinding remained intact. CONCLUSION The TNM™ device for CVS appears to provide a clinically efficacious and highly tolerable adjuvant therapy for the prevention of episodic migraine.
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Affiliation(s)
- David Wilkinson
- School of Psychology, University of Kent, Canterbury, Kent, UK
| | | | | | - Deborah K Attix
- Department of Neurology, Duke University Medical Center, Durham, NC
| | - Maragatha Kuchibhatla
- Department of Biostatistics and Bioinformatics, Duke University Medical Center, Durham, NC
| | | | | | | | | | | | - Michael E Hoffer
- Department of Otolaryngology, University of Miami Miller School of Medicine, Miami, FL
| | - Joel R Saper
- Michigan Headache and Neurological Institute, Ann Arbor, MI
| | - Dianne L Scott
- Department of Anesthesiology, Duke University Medical Center, Durham, NC, USA
| | - Mohamed Sakel
- East Kent Neuro-Rehabilitation Service, East Kent Hospitals University NHS Foundation Trust, Canterbury, Kent, UK
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Abstract
Postural tachycardia syndrome (POTS) represents a common form of orthostatic intolerance that disproportionately affects young women from puberty through adulthood. Patients with POTS have day-to-day orthostatic symptoms with the hallmark feature of an excessive, sustained, and symptomatic rise in heart rate during orthostatic testing. Although considerable overlap exists, three subtypes of POTS have been described: neuropathic, hyperadrenergic, and hypovolemic forms. The wide spectrum of symptoms and comorbidities can make treatment particularly challenging. Volume expansion with fluid and salt, exercise, and education constitute a reasonable initial therapy for most patients. Several medicines are also available to treat orthostatic intolerance and the associated comorbidities. Defining the POTS subtypes clinically in each patient may help to guide medicine choices. A multidisciplinary approach to overall management of the patient with POTS is advised. This review highlights several aspects of POTS with a specific focus on adolescent and young adult patients. [Pediatr Ann. 2017;46(4):e145-e154.].
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Powers SW, Coffey CS, Chamberlin LA, Ecklund DJ, Klingner EA, Yankey JW, Korbee LL, Porter LL, Hershey AD. Trial of Amitriptyline, Topiramate, and Placebo for Pediatric Migraine. N Engl J Med 2017; 376:115-124. [PMID: 27788026 PMCID: PMC5226887 DOI: 10.1056/nejmoa1610384] [Citation(s) in RCA: 197] [Impact Index Per Article: 28.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Which medication, if any, to use to prevent the headache of pediatric migraine has not been established. METHODS We conducted a randomized, double-blind, placebo-controlled trial of amitriptyline (1 mg per kilogram of body weight per day), topiramate (2 mg per kilogram per day), and placebo in children and adolescents 8 to 17 years of age with migraine. Patients were randomly assigned in a 2:2:1 ratio to receive one of the medications or placebo. The primary outcome was a relative reduction of 50% or more in the number of headache days in the comparison of the 28-day baseline period with the last 28 days of a 24-week trial. Secondary outcomes were headache-related disability, headache days, number of trial completers, and serious adverse events that emerged during treatment. RESULTS A total of 361 patients underwent randomization, and 328 were included in the primary efficacy analysis (132 in the amitriptyline group, 130 in the topiramate group, and 66 in the placebo group). The trial was concluded early for futility after a planned interim analysis. There were no significant between-group differences in the primary outcome, which occurred in 52% of the patients in the amitriptyline group, 55% of those in the topiramate group, and 61% of those in the placebo group (amitriptyline vs. placebo, P=0.26; topiramate vs. placebo, P=0.48; amitriptyline vs. topiramate, P=0.49). There were also no significant between-group differences in headache-related disability, headache days, or the percentage of patients who completed the 24-week treatment period. Patients who received amitriptyline or topiramate had higher rates of several adverse events than those receiving placebo, including fatigue (30% vs. 14%) and dry mouth (25% vs. 12%) in the amitriptyline group and paresthesia (31% vs. 8%) and weight loss (8% vs. 0%) in the topiramate group. Three patients in the amitriptyline group had serious adverse events of altered mood, and one patient in the topiramate group had a suicide attempt. CONCLUSIONS There were no significant differences in reduction in headache frequency or headache-related disability in childhood and adolescent migraine with amitriptyline, topiramate, or placebo over a period of 24 weeks. The active drugs were associated with higher rates of adverse events. (Funded by the National Institutes of Health; CHAMP ClinicalTrials.gov number, NCT01581281 ).
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Affiliation(s)
- Scott W Powers
- From the Department of Pediatrics, University of Cincinnati College of Medicine (S.W.P., A.D.H.), and the Division of Behavioral Medicine and Clinical Psychology (S.W.P., L.A.C.), the Office for Clinical and Translational Research (L.L.K.), and the Division of Neurology (A.D.H.), Cincinnati Children's Hospital Medical Center - all in Cincinnati; the Department of Biostatistics, Clinical Trials Statistical and Data Management Center, University of Iowa, Iowa City (C.S.C., D.J.E., E.A.K., J.W.Y.); and the National Institute of Neurological Disorders and Stroke, Bethesda, MD (L.L.P.)
| | - Christopher S Coffey
- From the Department of Pediatrics, University of Cincinnati College of Medicine (S.W.P., A.D.H.), and the Division of Behavioral Medicine and Clinical Psychology (S.W.P., L.A.C.), the Office for Clinical and Translational Research (L.L.K.), and the Division of Neurology (A.D.H.), Cincinnati Children's Hospital Medical Center - all in Cincinnati; the Department of Biostatistics, Clinical Trials Statistical and Data Management Center, University of Iowa, Iowa City (C.S.C., D.J.E., E.A.K., J.W.Y.); and the National Institute of Neurological Disorders and Stroke, Bethesda, MD (L.L.P.)
| | - Leigh A Chamberlin
- From the Department of Pediatrics, University of Cincinnati College of Medicine (S.W.P., A.D.H.), and the Division of Behavioral Medicine and Clinical Psychology (S.W.P., L.A.C.), the Office for Clinical and Translational Research (L.L.K.), and the Division of Neurology (A.D.H.), Cincinnati Children's Hospital Medical Center - all in Cincinnati; the Department of Biostatistics, Clinical Trials Statistical and Data Management Center, University of Iowa, Iowa City (C.S.C., D.J.E., E.A.K., J.W.Y.); and the National Institute of Neurological Disorders and Stroke, Bethesda, MD (L.L.P.)
| | - Dixie J Ecklund
- From the Department of Pediatrics, University of Cincinnati College of Medicine (S.W.P., A.D.H.), and the Division of Behavioral Medicine and Clinical Psychology (S.W.P., L.A.C.), the Office for Clinical and Translational Research (L.L.K.), and the Division of Neurology (A.D.H.), Cincinnati Children's Hospital Medical Center - all in Cincinnati; the Department of Biostatistics, Clinical Trials Statistical and Data Management Center, University of Iowa, Iowa City (C.S.C., D.J.E., E.A.K., J.W.Y.); and the National Institute of Neurological Disorders and Stroke, Bethesda, MD (L.L.P.)
| | - Elizabeth A Klingner
- From the Department of Pediatrics, University of Cincinnati College of Medicine (S.W.P., A.D.H.), and the Division of Behavioral Medicine and Clinical Psychology (S.W.P., L.A.C.), the Office for Clinical and Translational Research (L.L.K.), and the Division of Neurology (A.D.H.), Cincinnati Children's Hospital Medical Center - all in Cincinnati; the Department of Biostatistics, Clinical Trials Statistical and Data Management Center, University of Iowa, Iowa City (C.S.C., D.J.E., E.A.K., J.W.Y.); and the National Institute of Neurological Disorders and Stroke, Bethesda, MD (L.L.P.)
| | - Jon W Yankey
- From the Department of Pediatrics, University of Cincinnati College of Medicine (S.W.P., A.D.H.), and the Division of Behavioral Medicine and Clinical Psychology (S.W.P., L.A.C.), the Office for Clinical and Translational Research (L.L.K.), and the Division of Neurology (A.D.H.), Cincinnati Children's Hospital Medical Center - all in Cincinnati; the Department of Biostatistics, Clinical Trials Statistical and Data Management Center, University of Iowa, Iowa City (C.S.C., D.J.E., E.A.K., J.W.Y.); and the National Institute of Neurological Disorders and Stroke, Bethesda, MD (L.L.P.)
| | - Leslie L Korbee
- From the Department of Pediatrics, University of Cincinnati College of Medicine (S.W.P., A.D.H.), and the Division of Behavioral Medicine and Clinical Psychology (S.W.P., L.A.C.), the Office for Clinical and Translational Research (L.L.K.), and the Division of Neurology (A.D.H.), Cincinnati Children's Hospital Medical Center - all in Cincinnati; the Department of Biostatistics, Clinical Trials Statistical and Data Management Center, University of Iowa, Iowa City (C.S.C., D.J.E., E.A.K., J.W.Y.); and the National Institute of Neurological Disorders and Stroke, Bethesda, MD (L.L.P.)
| | - Linda L Porter
- From the Department of Pediatrics, University of Cincinnati College of Medicine (S.W.P., A.D.H.), and the Division of Behavioral Medicine and Clinical Psychology (S.W.P., L.A.C.), the Office for Clinical and Translational Research (L.L.K.), and the Division of Neurology (A.D.H.), Cincinnati Children's Hospital Medical Center - all in Cincinnati; the Department of Biostatistics, Clinical Trials Statistical and Data Management Center, University of Iowa, Iowa City (C.S.C., D.J.E., E.A.K., J.W.Y.); and the National Institute of Neurological Disorders and Stroke, Bethesda, MD (L.L.P.)
| | - Andrew D Hershey
- From the Department of Pediatrics, University of Cincinnati College of Medicine (S.W.P., A.D.H.), and the Division of Behavioral Medicine and Clinical Psychology (S.W.P., L.A.C.), the Office for Clinical and Translational Research (L.L.K.), and the Division of Neurology (A.D.H.), Cincinnati Children's Hospital Medical Center - all in Cincinnati; the Department of Biostatistics, Clinical Trials Statistical and Data Management Center, University of Iowa, Iowa City (C.S.C., D.J.E., E.A.K., J.W.Y.); and the National Institute of Neurological Disorders and Stroke, Bethesda, MD (L.L.P.)
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40
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Affiliation(s)
- Jeffrey L Jackson
- From the General Internal Medicine Section, Zablocki Veterans Affairs Medical Center, and the Department of Medicine, Medical College of Wisconsin - both in Milwaukee
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Friedrichsdorf SJ, Giordano J, Desai Dakoji K, Warmuth A, Daughtry C, Schulz CA. Chronic Pain in Children and Adolescents: Diagnosis and Treatment of Primary Pain Disorders in Head, Abdomen, Muscles and Joints. CHILDREN (BASEL, SWITZERLAND) 2016; 3:E42. [PMID: 27973405 PMCID: PMC5184817 DOI: 10.3390/children3040042] [Citation(s) in RCA: 62] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/31/2016] [Revised: 11/26/2016] [Accepted: 12/01/2016] [Indexed: 12/12/2022]
Abstract
Primary pain disorders (formerly "functional pain syndromes") are common, under-diagnosed and under-treated in children and teenagers. This manuscript reviews key aspects which support understanding the development of pediatric chronic pain, points to the current pediatric chronic pain terminology, addresses effective treatment strategies, and discusses the evidence-based use of pharmacology. Common symptoms of an underlying pain vulnerability present in the three most common chronic pain disorders in pediatrics: primary headaches, centrally mediated abdominal pain syndromes, and/or chronic/recurrent musculoskeletal and joint pain. A significant number of children with repeated acute nociceptive pain episodes develop chronic pain in addition to or as a result of their underlying medical condition "chronic-on-acute pain." We provide description of the structure and process of our interdisciplinary, rehabilitative pain clinic in Minneapolis, Minnesota, USA with accompanying data in the treatment of chronic pain symptoms that persist beyond the expected time of healing. An interdisciplinary approach combining (1) rehabilitation; (2) integrative medicine/active mind-body techniques; (3) psychology; and (4) normalizing daily school attendance, sports, social life and sleep will be presented. As a result of restored function, pain improves and commonly resolves. Opioids are not indicated for primary pain disorders, and other medications, with few exceptions, are usually not first-line therapy.
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Affiliation(s)
- Stefan J Friedrichsdorf
- Children's Hospitals and Clinics of Minnesota, Minneapolis, MN 55404, USA.
- Department of Pediatrics, University of Minnesota Medical School, Minneapolis, MN 55455, USA.
| | - James Giordano
- Georgetown University Medical Center, Washington, DC 20057, USA.
| | | | - Andrew Warmuth
- Children's Hospitals and Clinics of Minnesota, Minneapolis, MN 55404, USA.
| | - Cyndee Daughtry
- Children's Hospitals and Clinics of Minnesota, Minneapolis, MN 55404, USA.
| | - Craig A Schulz
- Children's Hospitals and Clinics of Minnesota, Minneapolis, MN 55404, USA.
- Center for Spirituality & Healing, University of Minnesota, Minneapolis, MN 55455, USA.
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Szperka CL, Gelfand AA, Hershey AD. Patterns of Use of Peripheral Nerve Blocks and Trigger Point Injections for Pediatric Headache: Results of a Survey of the American Headache Society Pediatric and Adolescent Section. Headache 2016; 56:1597-1607. [PMID: 27731894 DOI: 10.1111/head.12939] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/08/2016] [Indexed: 12/29/2022]
Abstract
OBJECTIVE To describe current patterns of use of nerve blocks and trigger point injections for treatment of pediatric headache. BACKGROUND Peripheral nerve blocks are often used to treat headaches in adults and children, but the available studies and practice data from adult headache specialists have shown wide variability in diagnostic indications, sites injected, and medication(s) used. The purpose of this study was to describe current practice patterns in the use of nerve blocks and trigger point injections for pediatric headache disorders. METHODS A survey was created in REDCap, and sent via email to the 82 members of the Pediatric and Adolescent Section of the American Headache Society in June 2015. The survey queried about current practice and use of nerve blocks, as well as respondents' opinions regarding gaps in the evidence for use of nerve blocks in this patient population. RESULTS Forty-one complete, five incomplete, and three duplicate responses were submitted (response rate complete 50%). About 78% of the respondents identified their primary specialty as Child Neurology, and 51% were certified in headache medicine. Twenty-six (63%) respondents perform nerve blocks themselves, and seven (17%) refer patients to another provider for nerve blocks. Chronic migraine with status migrainosus was the most common indication for nerve blocks (82%), though occipital neuralgia (79%), status migrainosus (73%), chronic migraine without flare (70%), post-traumatic headache (70%), and new daily persistent headache (67%) were also common indications. The most commonly selected clinically meaningful response for status migrainosus was ≥50% reduction in severity, while for chronic migraine this was a ≥50% decrease in frequency at 4 weeks. Respondents inject the following locations: 100% inject the greater occipital nerve, 69% lesser occipital nerve, 50% supraorbital, 46% trigger point injections, 42% auriculotemporal, and 34% supratrochlear. All respondents used local anesthetic, while 12 (46%) also use corticosteroid (8 bupivacaine only, 4 each lidocaine + bupivacaine, lidocaine + corticosteroid, bupivacaine + corticosteroid, lidocaine + bupivacaine + corticosteroid, and 2 lidocaine only). CONCLUSION Despite limited evidence, nerve blocks are commonly used by pediatric headache specialists. There is considerable variability among clinicians as to injection site(s) and medication selection, indicating a substantial gap in the literature to guide practice, and supporting the need for further research in this area.
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Affiliation(s)
- Christina L Szperka
- Department of Neurology, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, USA.,Division of Neurology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Amy A Gelfand
- Departments of Neurology and Pediatrics, University of California San Francisco (UCSF), San Francisco, CA, USA
| | - Andrew D Hershey
- Department of Pediatrics, University of Cincinnati, College of Medicine, Cincinnati, OH, USA.,Division of Neurology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
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Abstract
Adolescents and children are frequently affected by chronic pain conditions that can lead to disability and distress. The best approach to evaluation and treatment of these conditions involves use of the biopsychosocial model, which includes use of medication management. Chronic pain conditions are treated pharmacologically with a number of different medication classes via several routes of administration as drug delivery systems have progressed. These include anti-inflammatory drugs, muscle relaxants, antiepileptic medicines, antidepressants, opioids, and local anesthetics. Most are prescribed without regulatory body approval to treat specific pain syndromes as data to support their use are sparse. Medical decision making is guided by experience, empiric evidence, extrapolation from adult studies, and matching medication classes with the theorized mechanism of the pain condition. It is not recommended that nonpain practitioners prescribe opioid medications for treatment of chronic pain conditions, and pain management practitioners should seek to minimize their use. The appropriate and commonly used medications for pain conditions are presented in this narrative review.
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Affiliation(s)
- Eapen Mathew
- Department of Anesthesiology, Frank Netter School of Medicine, Quinnipiac University, North Haven, CT; Department of Anesthesiology, Connecticut Children's Medical Center, Hartford, CT; Department of Anesthesiology, University of Connecticut School of Medicine, Farmington, CT; Division of Pain and Palliative Medicine, Connecticut Children's Medical Center, Hartford, CT; Department of Pediatrics, University of Connecticut School of Medicine, Farmington, CT.
| | - Eugene Kim
- Department of Anesthesiology, Keck School of Medicine of the University of Southern California, Los Angeles, CA; Department of Anesthesiology, Children's Hospital of Los Angeles, Los Angeles, CA
| | - William Zempsky
- Division of Pain and Palliative Medicine, Connecticut Children's Medical Center, Hartford, CT; Department of Pediatrics, University of Connecticut School of Medicine, Farmington, CT
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Golub MS, Hogrefe CE. Sleep disturbance as detected by actigraphy in pre-pubertal juvenile monkeys receiving therapeutic doses of fluoxetine. Neurotoxicol Teratol 2016; 55:1-7. [PMID: 26956991 PMCID: PMC4884518 DOI: 10.1016/j.ntt.2016.02.006] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2015] [Revised: 02/25/2016] [Accepted: 02/29/2016] [Indexed: 12/19/2022]
Abstract
Sleep disturbance is a reported side effect of antidepressant drugs in children. Using a nonhuman primate model of childhood selective serotonin reuptake inhibitor (SSRI) therapy, sleep was studied quantitatively with actigraphy. Two 48-h sessions were recorded in the home cage environment of juvenile male rhesus monkeys at two and three years of age, after one and two years of treatment with a therapeutic dose of the SSRI fluoxetine, and compared to vehicle treated controls. A third session was conducted one year after discontinuation of treatment at four years of age. During treatment, the fluoxetine group demonstrated sleep fragmentation as indexed by a greater number of rest-activity transitions compared to controls. In addition fluoxetine led to more inactivity during the day as indexed by longer duration of rest periods and the reduced activity during these periods. The fluoxetine effect on sleep fragmentation, but not on daytime rest, was modified by the monkey's genotype for polymorphisms of monoamine oxidase A (MAOA), an enzyme that metabolizes serotonin. After treatment, the fluoxetine effect on nighttime rest-activity transitions persisted, but daytime activity was not affected. The demonstration in this nonhuman primate model of sleep disturbance in connection with fluoxetine treatment and specific genetic polymorphisms, and in the absence of diagnosed psychopathology, can help inform use of this drug in children.
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Affiliation(s)
- Mari S Golub
- Department of Environmental Toxicology, University of California Davis, One Shields Ave, Davis, CA 95616, USA.
| | - Casey E Hogrefe
- California National Primate Research Center, University of California Davis, One Shields Ave, Davis, CA 95616, USA.
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Kacperski J, Kabbouche MA, O’Brien HL, Weberding JL. The optimal management of headaches in children and adolescents. Ther Adv Neurol Disord 2016; 9:53-68. [PMID: 26788131 PMCID: PMC4710107 DOI: 10.1177/1756285615616586] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
The recognition of the diagnosis of migraine in children is increasing. Early and aggressive treatment of migraine in this population with the use of over-the-counter medications has proven effective. The off-label use of many migraine-specific medications is often accepted in the absence of sufficient evidenced-based trials. Mild to severe cases of migraine should be treated with nonsteroidal anti-inflammatory drugs, with triptans used in moderate to severe headaches unresponsive to over-the-counter therapy. Rescue medication including dihydroergotamine [DHE] should be used for status migrainosus, preferably in the hospital setting. Antiemetics that have antidopaminergic properties can be helpful in patients with associated symptoms of nausea and vomiting through their action on central migraine generation. Furthermore, patients and families should be educated on nonpharmacologic management such as lifestyle modification and avoidance of triggers that can prevent episodic migraine.
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Affiliation(s)
- Joanne Kacperski
- Division of Neurology, Cincinnati Children’s Hospital Medical Center, University of Cincinnati College of Medicine, 3333 Burnett Avenue, Cincinnati, OH 45229, USA
| | - Marielle A. Kabbouche
- Division of Neurology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA and University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Hope L. O’Brien
- Division of Neurology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA and University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Jessica L. Weberding
- Division of Neurology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
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Prophylactic Drug Treatment of Migraine in Children and Adolescents: An Update. Curr Pain Headache Rep 2015; 20:1. [DOI: 10.1007/s11916-015-0536-6] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
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Hickman C, Lewis KS, Little R, Rastogi RG, Yonker M. Prevention for Pediatric and Adolescent Migraine. Headache 2015; 55:1371-81. [DOI: 10.1111/head.12699] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/09/2015] [Indexed: 01/23/2023]
Affiliation(s)
- Carolyn Hickman
- Barrow Neurological Institute at Phoenix Children's Hospital; Phoenix AZ USA
| | - Kara Stuart Lewis
- Barrow Neurological Institute at Phoenix Children's Hospital; Phoenix AZ USA
- College of Medicine, University of Arizona Phoenix; AZ USA
| | - Robert Little
- Barrow Neurological Institute at Phoenix Children's Hospital; Phoenix AZ USA
- College of Medicine, University of Arizona Phoenix; AZ USA
- Creighton University; Omaha NE USA
| | - Reena Gogia Rastogi
- Barrow Neurological Institute at Phoenix Children's Hospital; Phoenix AZ USA
| | - Marcy Yonker
- Barrow Neurological Institute at Phoenix Children's Hospital; Phoenix AZ USA
- College of Medicine, University of Arizona Phoenix; AZ USA
- Mayo Clinic; Scottsdale AZ USA
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Curie A, Yang K, Kirsch I, Gollub RL, des Portes V, Kaptchuk TJ, Jensen KB. Placebo Responses in Genetically Determined Intellectual Disability: A Meta-Analysis. PLoS One 2015; 10:e0133316. [PMID: 26226597 PMCID: PMC4520690 DOI: 10.1371/journal.pone.0133316] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2015] [Accepted: 06/25/2015] [Indexed: 12/01/2022] Open
Abstract
Background Genetically determined Intellectual Disability (ID) is an intractable condition that involves severe impairment of mental abilities such as learning, reasoning and predicting the future. As of today, little is known about the placebo response in patients with ID. Objective To determine if placebo response exists in patients with genetically determined ID. Data sources and Study selection We searched Medline/PubMed, EMBASE, CENTRAL and PsycINFO to find all placebo-controlled double-blind randomized clinical trials (RCTs) in patients with genetically determined ID, published up to April 2013, focusing on core ID symptoms. Data extraction and synthesis Two investigators extracted outcome data independently. Main outcomes and measures Bias-corrected standardized mean difference (Hedge’s g) was computed for each outcome measure, using the Comprehensive Meta-Analysis software. A priori defined patient sub-groups were analyzed using a mixed-effect model. The relationship between pre-defined continuous variable moderators (age, IQ, year of publication and trial duration) and effect size was analyzed using meta-regression Results Twenty-two placebo-controlled double-blind RCTs met the inclusion criteria (n = 721, mean age = 17.1 years, 62% men, mean trial duration = 35 weeks). There was a significant overall placebo response from pre- to post-treatment in patients with ID (g = 0.468, p = 0.002), both for “subjective outcomes” (a third-person’s evaluation of the patient) (g = 0.563, p = 0.022) and “objective outcomes” (direct evaluation of the patient’s abilities) (g = 0.434, p = 0.036). Individuals with higher IQ had higher response to placebo (p = 0.02) and no placebo response was observed in ID patients with comorbid dementia. A significant effect of age (p = 0.02) was found, indicating higher placebo responses in treatment of younger patients. Conclusions and relevance Results suggest that patients with genetically determined ID improve in the placebo arm of RCTs. Several mechanisms may contribute to placebo effects in ID, including expectancy, implicit learning and “placebo-by-proxy” induced by clinicians/family members. As the condition is refractory, there is little risk that improvements are explained by spontaneous remission. While new avenues for treatment of genetically determined ID are emerging, our results demonstrate how contextual factors can affect clinical outcomes and emphasize the importance of being vigilant on the role of placebos when testing novel treatments in ID.
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Affiliation(s)
- Aurore Curie
- Department of Psychiatry, Massachusetts General Hospital/Harvard Medical School, Martinos Center for Biomedical Imaging, Boston, Massachusetts, United States of America
- L2C2, Institut des Sciences Cognitives, CNRS UMR5304, Bron, France
- Centre de Référence Déficiences Intellectuelles de Causes Rares, Hôpital Femmes Mères Enfants, Hospices Civils de Lyon, Bron, France
- Université Claude Bernard Lyon1, Lyon, France
- EPICIME-CIC1407/INSERM, Bron, France
- * E-mail:
| | - Kathy Yang
- Department of Psychiatry, Massachusetts General Hospital/Harvard Medical School, Martinos Center for Biomedical Imaging, Boston, Massachusetts, United States of America
| | - Irving Kirsch
- Program in Placebo Studies, Beth Israel Deaconess Medical Center/Harvard Medical School, Boston, Massachusetts, United States of America
- School of Psychology, Plymouth University, Plymouth, United Kingdom
| | - Randy L. Gollub
- Department of Psychiatry, Massachusetts General Hospital/Harvard Medical School, Martinos Center for Biomedical Imaging, Boston, Massachusetts, United States of America
| | - Vincent des Portes
- L2C2, Institut des Sciences Cognitives, CNRS UMR5304, Bron, France
- Centre de Référence Déficiences Intellectuelles de Causes Rares, Hôpital Femmes Mères Enfants, Hospices Civils de Lyon, Bron, France
- Université Claude Bernard Lyon1, Lyon, France
| | - Ted J. Kaptchuk
- Program in Placebo Studies, Beth Israel Deaconess Medical Center/Harvard Medical School, Boston, Massachusetts, United States of America
| | - Karin B. Jensen
- Department of Psychiatry, Massachusetts General Hospital/Harvard Medical School, Martinos Center for Biomedical Imaging, Boston, Massachusetts, United States of America
- Program in Placebo Studies, Beth Israel Deaconess Medical Center/Harvard Medical School, Boston, Massachusetts, United States of America
- Department of Clinical Neuroscience, Karolinska Institute, Stockholm, Sweden
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Jackson JL, Cogbill E, Santana-Davila R, Eldredge C, Collier W, Gradall A, Sehgal N, Kuester J. A Comparative Effectiveness Meta-Analysis of Drugs for the Prophylaxis of Migraine Headache. PLoS One 2015; 10:e0130733. [PMID: 26172390 PMCID: PMC4501738 DOI: 10.1371/journal.pone.0130733] [Citation(s) in RCA: 146] [Impact Index Per Article: 16.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2014] [Accepted: 05/24/2015] [Indexed: 01/03/2023] Open
Abstract
Objective To compare the effectiveness and side effects of migraine prophylactic medications. Design We performed a network meta-analysis. Data were extracted independently in duplicate and quality was assessed using both the JADAD and Cochrane Risk of Bias instruments. Data were pooled and network meta-analysis performed using random effects models. Data Sources PUBMED, EMBASE, Cochrane Trial Registry, bibliography of retrieved articles through 18 May 2014. Eligibility Criteria for Selecting Studies We included randomized controlled trials of adults with migraine headaches of at least 4 weeks in duration. Results Placebo controlled trials included alpha blockers (n = 9), angiotensin converting enzyme inhibitors (n = 3), angiotensin receptor blockers (n = 3), anticonvulsants (n = 32), beta-blockers (n = 39), calcium channel blockers (n = 12), flunarizine (n = 7), serotonin reuptake inhibitors (n = 6), serotonin norepinephrine reuptake inhibitors (n = 1) serotonin agonists (n = 9) and tricyclic antidepressants (n = 11). In addition there were 53 trials comparing different drugs. Drugs with at least 3 trials that were more effective than placebo for episodic migraines included amitriptyline (SMD: -1.2, 95% CI: -1.7 to -0.82), -flunarizine (-1.1 headaches/month (ha/month), 95% CI: -1.6 to -0.67), fluoxetine (SMD: -0.57, 95% CI: -0.97 to -0.17), metoprolol (-0.94 ha/month, 95% CI: -1.4 to -0.46), pizotifen (-0.43 ha/month, 95% CI: -0.6 to -0.21), propranolol (-1.3 ha/month, 95% CI: -2.0 to -0.62), topiramate (-1.1 ha/month, 95% CI: -1.9 to -0.73) and valproate (-1.5 ha/month, 95% CI: -2.1 to -0.8). Several effective drugs with less than 3 trials included: 3 ace inhibitors (enalapril, lisinopril, captopril), two angiotensin receptor blockers (candesartan, telmisartan), two anticonvulsants (lamotrigine, levetiracetam), and several beta-blockers (atenolol, bisoprolol, timolol). Network meta-analysis found amitriptyline to be better than several other medications including candesartan, fluoxetine, propranolol, topiramate and valproate and no different than atenolol, flunarizine, clomipramine or metoprolol. Conclusion Several drugs good evidence supporting efficacy. There is weak evidence supporting amitriptyline’s superiority over some drugs. Selection of prophylactic medication should be tailored according to patient preferences, characteristics and side effect profiles.
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Affiliation(s)
- Jeffrey L. Jackson
- General Internal Medicine, Zablocki VA Medical Center, Milwaukee, Wisconsin, United States of America
- * E-mail:
| | - Elizabeth Cogbill
- Department of Medicine, Western Michigan School of Medicine, Kalamazoo, Michigan, United States of America
| | - Rafael Santana-Davila
- Division of Hematology and Oncology, University of Washington, Seattle, Washington, United States of America
| | - Christina Eldredge
- Department of Family and Community Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin, United States of America
| | - William Collier
- Department of Pharmacology, Medical College of Wisconsin, Milwaukee, Wisconsin, United States of America
| | - Andrew Gradall
- School of Health Sciences, Gollis University, Hergaisa, Somaliland
| | - Neha Sehgal
- Medical College of Wisconsin, Milwaukee, Wisconsin, United States of America
| | - Jessica Kuester
- General Internal Medicine, Zablocki VA Medical Center, Milwaukee, Wisconsin, United States of America
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Barnes NP. Migraine headache in children. BMJ CLINICAL EVIDENCE 2015; 2015:0318. [PMID: 26044059 PMCID: PMC4456852] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
INTRODUCTION Diagnosis of migraine headache in children can be difficult as it depends on subjective symptoms; diagnostic criteria are broader than in adults. Migraine occurs in 3% to 10% of children and increases with age up to puberty. Migraine spontaneously remits after puberty in half of children, but if it begins during adolescence it may be more likely to persist throughout adulthood. METHODS AND OUTCOMES We conducted a systematic review and aimed to answer the following clinical questions: What are the effects of treatments for acute attacks of migraine headache in children? What are the effects of pharmacological prophylaxis for migraine headache in children? We searched: Medline, Embase, The Cochrane Library, and other important databases up to June 2014 (Clinical Evidence reviews are updated periodically; please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA). RESULTS Twenty-three studies were included. We performed a GRADE evaluation of the quality of evidence for interventions. CONCLUSIONS In this systematic review we present information relating to the effectiveness and safety of the following interventions. For acute symptom relief: 5HT1 agonists [such as triptans], non-steroidal anti-inflammatory drugs [NSAIDs], and paracetamol. And, for prophylaxis: beta-blockers, flunarizine, pizotifen, and topiramate.
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