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Lax DN, White S, Manning P, Kabbouche Samaha M. Diagnostic Algorithm for Pediatric Headaches: A Clinical Improvement Initiative. Pediatr Neurol 2023; 149:108-113. [PMID: 37839338 DOI: 10.1016/j.pediatrneurol.2023.09.009] [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: 12/30/2022] [Revised: 07/16/2023] [Accepted: 09/18/2023] [Indexed: 10/17/2023]
Abstract
BACKGROUND The widespread variation in diagnosing primary headache disorders in children and adolescents results in reduced quality and high costs. Defining an algorithm for primary headache diagnoses in children and adolescents is part of a larger initiative to standardize and improve care. The aim of this algorithm was to increase the accuracy of headache diagnosis by formal criteria to more than 80% of patient encounters. METHODS A team of headache specialists, nurse practitioners, nurses, data analysts, and business specialists developed an algorithm based on available scientific evidence. This algorithm was vetted and adapted by the neurology faculty and headache specialists until final consensus was reached. Following three months of testing and validation, the algorithm was disseminated to general pediatric neurology clinics. The following information was gathered: percent of encounters utilizing the algorithm, percentage of encounters with appropriate diagnosis by formal criteria, percentage of encounters with appropriate testing ordered, and average cost per headache visit. RESULTS Correct diagnosis of primary headache by International Classification of Headache Disorders-3 criteria improved from 72% to 90% and appropriate testing improved from 80% to 94%. By the end of analysis, 94% of encounters were correctly implementing the algorithm. A year-long tracking revealed decreased cost of headache evaluation by 6% compared with the year prior. CONCLUSIONS A standardized algorithm improved the diagnostic accuracy in general child neurology clinics. Expanding the algorithm to primary care and pediatric emergency rooms could have a greater impact on headache evaluation and diagnosis; this should result in improved care and outcomes with reduced cost.
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Affiliation(s)
- Daniel N Lax
- Division of Neurology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.
| | - Shannon White
- Division of Neurology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Paula Manning
- Division of Neurology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Marielle Kabbouche Samaha
- Division of Neurology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; Department of Pediatrics, University of Cincinnati School of Medicine, Cincinnati, Ohio
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2
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Szperka CL, Witzman S, Ostapenko S, Farrar JT, Hsu JY, Malavolta CP, Bunney JD, Bange EM, Patterson Gentile C, Velasquez G, Marquez de Prado B, Cosico M, Lee M, Pojomovsky McDonnell P, Prelack MS, Chadehumbe MA, Stephenson DJ, Kichula EA, Tomaine SC, Hershey AD. Patient headache questionnaires can improve headache diagnosis and treatment in children. Headache 2023; 63:1359-1371. [PMID: 37975482 PMCID: PMC10836822 DOI: 10.1111/head.14643] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2023] [Revised: 10/04/2023] [Accepted: 10/05/2023] [Indexed: 11/19/2023]
Abstract
OBJECTIVE To examine trends in diagnosis of headache and migraine in a large pediatric neurology cohort, and test whether an electronic health record (EHR)-integrated headache questionnaire can increase specificity of diagnosis and likelihood of prescribing migraine treatment. BACKGROUND Under-diagnosis of migraine contributes to the burden of disease. As we founded our Pediatric Headache Program in 2013, we recognized that the proportion of patients with headache who were given a diagnosis of migraine was much lower than expected. METHODS We developed a patient headache questionnaire, initially on paper (2013-2014), then in an electronic database (2014-2016), and finally integrated into our electronic health record (pilot: 2016, full: May 2017). We compared diagnoses and prescribed treatments for new patients who were given a headache diagnosis, looking at trends in the proportion of patients given specific diagnoses (migraine, etc.) versus the non-specific diagnosis, "headache." Next, we conducted a prospective cohort study to test for association between provider use of the form and the presence of a specific diagnosis, then for an association between specific diagnosis and prescription of migraine treatment. RESULTS Between July 2011 and December 2022 the proportion of new headache patients who were given a diagnosis of migraine increased 9.7% and non-specific headache diagnoses decreased 21.0%. In the EHR cohort (June 2017-December 2022, n = 15,122), use of the provider form increased the rate of specific diagnosis to 87.2% (1839/2109) compared to 75.5% (5708/7560) without a patient questionnaire, nearly doubling the odds of making a specific diagnosis (odds ratio [OR] 1.90, 95% confidence interval [CI]: 1.65-2.19). Compared to those given only a non-specific headache diagnosis who were prescribed a migraine therapy 53.7% (1766/3286) of the time, 75.3% (8914/11836) of those given a specific diagnosis received a migraine therapy, more than doubling the odds of prescription (OR 2.39, 95% CI: 2.20-2.60). CONCLUSIONS Interventions to improve specificity of diagnosis were effective and led to increased rates of prescription of migraine treatments. These results have been sustained over several years. This headache questionnaire was adapted into the Foundation system of EpicCare, so it is broadly available as a clinical and research tool for institutions that use this EHR software.
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Affiliation(s)
- Christina L Szperka
- Department of Neurology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Stephanie Witzman
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | | | - John T Farrar
- Department of Neurology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Jesse Yenchih Hsu
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | | | - Janille D Bunney
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Erin M Bange
- Memorial Sloane Kettering Cancer Center, New York, New York, USA
| | - Carlyn Patterson Gentile
- Department of Neurology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | | | | | - Mahgenn Cosico
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Meyeon Lee
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Pamela Pojomovsky McDonnell
- Department of Neurology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Marisa S Prelack
- Department of Neurology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | | | - Donna J Stephenson
- Department of Neurology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Elizabeth A Kichula
- Department of Neurology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Scott C Tomaine
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Andrew D Hershey
- Department of Pediatrics, Cincinnati Children's Hospital and University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
- Department of Neurology, Cincinnati Children's Hospital and University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
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3
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Rossi R, Benetti S, Lauria B, Grasso G, Castagno E, Ricceri F, Bondone C, Versace A. Cardiovascular Risk Factors and Family History of Major Thrombotic Events in Children with Migraine: A 12-Year Retrospective Single-Centre Study. J Clin Med 2023; 12:jcm12072582. [PMID: 37048668 PMCID: PMC10095463 DOI: 10.3390/jcm12072582] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Revised: 03/22/2023] [Accepted: 03/27/2023] [Indexed: 04/14/2023] Open
Abstract
BACKGROUND Migraine is one of the most frequent primary headaches in childhood. The role of thrombotic predisposition in its pathogenesis is debated. Our aim was to analyse the cardiovascular risk factors and family history of major thrombotic events in children with migraine. METHODS A retrospective, single-centre study was performed over 12 years. Our headache centre record database was screened for migraine with aura (MA) and migraine without aura (MO) on the basis of the ICHD-II (until 2013) and III criteria. A control group of otherwise healthy children was recruited. Descriptive and multivariate analyses are provided; significance was set at p < 0.05. RESULTS Migraine was diagnosed in 930 children (24.7% MA); 73.3% were 9-14 years old. Children with MA were older (p < 0.001). A family history of cerebral ischemic events at ≤50 years old was more commonly reported by children with MA than those with MO (p < 0.001) and those in the control group (p = 0.001). Children with MA showed a higher risk of a family history of cerebral ischemic events at ≤50 years old than children with MO (OR: 2.6) and those in the control group (OR: 3.1). When comparing the family history of DVT, we observed a significantly increased risk for MA vs. MO (OR: 2.9). CONCLUSION A family history of cerebral ischemic events at ≤50 years old leads to an increased risk of MA. Further studies are needed to explore such an association.
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Affiliation(s)
- Roberta Rossi
- Department of Pediatric Emergency, Pediatric Headache Centre, Regina Margherita Children's Hospital, A.O.U. Città della Salute e della Scienza di Torino, Piazza Polonia 94, 10126 Turin, Italy
| | - Stefania Benetti
- Department of Pediatrics, Ospedale degli Infermi, ASL TO3, Via Rivalta 29, 10098 Rivoli, Italy
| | - Barbara Lauria
- Department of Pediatric Emergency, Pediatric Headache Centre, Regina Margherita Children's Hospital, A.O.U. Città della Salute e della Scienza di Torino, Piazza Polonia 94, 10126 Turin, Italy
| | - Giulia Grasso
- Department of Pediatric Emergency, Pediatric Headache Centre, Regina Margherita Children's Hospital, A.O.U. Città della Salute e della Scienza di Torino, Piazza Polonia 94, 10126 Turin, Italy
| | - Emanuele Castagno
- Department of Pediatric Emergency, Pediatric Headache Centre, Regina Margherita Children's Hospital, A.O.U. Città della Salute e della Scienza di Torino, Piazza Polonia 94, 10126 Turin, Italy
| | - Fulvio Ricceri
- Department of Clinical and Biological Sciences, University of Turin, Regione Gonzole 10, 10043 Orbassano, Italy
| | - Claudia Bondone
- Department of Pediatric Emergency, Pediatric Headache Centre, Regina Margherita Children's Hospital, A.O.U. Città della Salute e della Scienza di Torino, Piazza Polonia 94, 10126 Turin, Italy
| | - Antonia Versace
- Department of Pediatric Emergency, Pediatric Headache Centre, Regina Margherita Children's Hospital, A.O.U. Città della Salute e della Scienza di Torino, Piazza Polonia 94, 10126 Turin, Italy
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Vincent M, Viktrup L, Nicholson RA, Ossipov MH, Vargas BB. The not so hidden impact of interictal burden in migraine: A narrative review. Front Neurol 2022; 13:1032103. [PMID: 36408525 PMCID: PMC9669578 DOI: 10.3389/fneur.2022.1032103] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Accepted: 10/20/2022] [Indexed: 08/26/2023] Open
Abstract
Migraine is a highly prevalent neurological disease of varying attack frequency. Headache attacks that are accompanied by a combination of impact on daily activities, photophobia and/or nausea are most commonly migraine. The headache phase of a migraine attack has attracted more research, assessment tools and treatment goals than any other feature, characteristic, or phase of migraine. However, the migraine attack may encompass up to 4 phases: the prodrome, aura, headache phase and postdrome. There is growing recognition that the burden of migraine, including symptoms associated with the headache phase of the attack, may persist between migraine attacks, sometimes referred to as the "interictal phase." These include allodynia, hypersensitivity, photophobia, phonophobia, osmophobia, visual/vestibular disturbances and motion sickness. Subtle interictal clinical manifestations and a patient's trepidation to make plans or commitments due to the unpredictability of migraine attacks may contribute to poorer quality of life. However, there are only a few tools available to assess the interictal burden. Herein, we examine the recent advances in the recognition, description, and assessment of the interictal burden of migraine. We also highlight the value in patients feeling comfortable discussing the symptoms and overall burden of migraine when discussing migraine treatment needs with their provider.
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Affiliation(s)
| | - Lars Viktrup
- Eli Lilly and Company, Indianapolis, IN, United States
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5
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Conversion from chronic to episodic migraine in patients treated with galcanezumab in real life in Italy: the 12-month observational, longitudinal, cohort multicenter GARLIT experience. J Neurol 2022; 269:5848-5857. [PMID: 35763113 PMCID: PMC9243974 DOI: 10.1007/s00415-022-11226-4] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2022] [Revised: 06/10/2022] [Accepted: 06/10/2022] [Indexed: 01/01/2023]
Abstract
Objective To investigate in real-life the conversion from chronic migraine (CM) to episodic migraine (EM), specifically to EM with High-Frequency (HFEM: 8–14 monthly migraine days, MMDs), Medium-Frequency (MFEM, 4–7 MMDs), and Low-Frequency EM (LFEM, 0–3 MMDs), and its persistence during 1 year of treatment with galcanezumab. Methods Consecutive CM patients treated with galcanezumab completing 1 year of observation were enrolled. We collected data on MMDs, pain intensity (Numeric Rating Scale, NRS score), and monthly acute medication intake (MAMI) from baseline (V1) to the 12-month visit (V12). Results Of the 155 enrolled patients, 116 (around 75%) reverted to EM at every visit and 81 (52.3%) for the entire 1-year treatment. Patients with older onset age (p = 0.010) and fewer baseline MMDs (p = 0.005) reverted more frequently to EM. At V12, 83 participants (53.5%) presented MFEM or LFEM. Patients reverted to MFEM or LFEM for 7 months (25th 1, 75th 11). The medication overuse discontinuation rate at V12 was 82.8% and occurred for 11 months (25th 8, 75th 12). From baseline to V12, the MAMI decreased by 17 symptomatic drugs (p < 0.000001) while the NRS score reduced by almost 2 points (p < 0.000001). A consistent transition to EM for the entire treatment year was observed in 81 (52.3%) patients. Discussion The 1-year GARLIT experience suggests that more than half of CM patients treated with galcanezumab persistently reverted to EM in real life. Trial registration ClinicalTrials.gov NCT04803513. Supplementary Information The online version contains supplementary material available at 10.1007/s00415-022-11226-4.
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Gazerani P. Migraine and Mood in Children. Behav Sci (Basel) 2021; 11:bs11040052. [PMID: 33919881 PMCID: PMC8070834 DOI: 10.3390/bs11040052] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Revised: 04/11/2021] [Accepted: 04/12/2021] [Indexed: 02/07/2023] Open
Abstract
Migraine is one of the most prevalent headache disorders in children and negatively influences their quality of life. Physical, social, and school functioning are negatively affected. Mood changes are common in migraineurs and may happen before, during, or after a migraine headache. Children with migraine are not exempt from mood swings. The majority of mood changes occur during the prodromal phase, manifesting as a psychobiological response, e.g., difficulty thinking, trouble concentrating, irritability, higher or lower energy, confusion, and depression. A bi-directional relationship between migraine and mood has been proposed, but mechanisms are not clear. Collectively, a maladaptive stress response has been suggested to explain the inability to balance homoeostatic changes when facing various stressors. Recognizing mood changes and monitoring mood patterns in children with migraine, for example, by various apps and so-called mood monitors, is valuable for better management. A multidisciplinary intervention has been recommended to reduce migraine disability, improve coping strategies, and reduce chronification risks in children with migraine. Pharmacological and non-pharmacological strategies are both available and effective. Biofeedback, relaxation, and cognitive-behavioral therapy yield positive outcomes in pediatric migraine. Developing healthy lifestyle habits (diet, exercise, sleep) also seems to improve migraine in this population.
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Affiliation(s)
- Parisa Gazerani
- Department of Life Sciences and Health, Faculty of Health Sciences, Oslo Metropolitan University, 0130 Oslo, Norway;
- Department of Health Science and Technology, Faculty of Medicine, Aalborg University, 9229 Aalborg E, Denmark;
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7
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Esparham A, Boorigie M, Ablatt S, Connelly M, Bickel J. Improving Acute Treatment of Pediatric Primary Headache Disorders With a Novel Headache Treatment Center: Retrospective Review of Preliminary Outcomes. J Child Neurol 2021; 36:54-59. [PMID: 32873117 DOI: 10.1177/0883073820952997] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To determine preliminary outcomes of targeted headache treatments provided at a novel outpatient acute care pediatric headache treatment center. BACKGROUND Limitations exist in acute management of pediatric headaches, including inadequate access to specialty headache therapies and headache specialists in acute settings, variable success of emergency room treatments, and omission of comfort measures. An outpatient acute headache care clinic (the "Headache Treatment Center") was strategically initiated at a Midwestern pediatric academic hospital to provide acute and targeted headache therapies for children with active headaches. METHODS We conducted a retrospective chart review of 154 visits from September through November 2018 of patients ages 7-18 years visiting the Headache Treatment Center. RESULTS On average, headache intensity (measured on an 11-point pain numeric rating scale) decreased after interventions used in the Headache Treatment Center (mean change = 2.85 ± 2.81, P < .05, Cohen d = 1.01). Large effect sizes for reducing headache intensity were observed for pericranial, occipital/auriculotemporal, and occipital nerve blocks, Cohen d = 1.56, 1.64 and 1.02, respectively. Large effect sizes for reducing headache intensity also were observed for a transcutaneous supraorbital nerve stimulator device (Cefaly) (Cohen d = 1.02), acupuncture (Cohen d = 1.09), and intravenous migraine cocktails (Cohen d = 0.91-1.34). CONCLUSION Targeted headache therapies to abort pediatric primary headaches as part of a novel headache clinic model may be beneficial for short-term management.
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Affiliation(s)
- Anna Esparham
- 4204Children's Mercy Hospitals and Clinics, Kansas City, MO, USA
| | | | - Saniya Ablatt
- 4204Children's Mercy Hospitals and Clinics, Kansas City, MO, USA
| | - Mark Connelly
- 4204Children's Mercy Hospitals and Clinics, Kansas City, MO, USA
| | - Jennifer Bickel
- 4204Children's Mercy Hospitals and Clinics, Kansas City, MO, USA
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Connelly MA, Boorigie ME. Feasibility of using "SMARTER" methodology for monitoring precipitating conditions of pediatric migraine episodes. Headache 2020; 61:500-510. [PMID: 33382086 DOI: 10.1111/head.14028] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Revised: 10/08/2020] [Accepted: 10/09/2020] [Indexed: 01/11/2023]
Abstract
OBJECTIVE To evaluate the feasibility in children of an intensive prospective data monitoring methodology for identifying precipitating conditions for migraine occurrence. BACKGROUND Migraine headaches are a common pain condition in childhood and can become increasingly chronic and disabling with repeated episodes. Identifying conditions that forecast when a child's migraine is likely to occur may facilitate next-generation adaptive treatments to prevent future migraine attacks. METHODS In this cohort study of a sample of 30 youth (ages 10-17) with migraine recruited through a pediatric headache clinic, smartphones supplemented with wearable biosensors were used over a period of 28 days to collect contextual data thought to be potentially relevant to headache occurrence. Self-reported data on headache occurrence, lifestyle, and perceptions of the environment were collected in 4 epochs per day using custom real-time reporting software. Data derived from the wearable biosensor included information on autonomic arousal and physical activity. Built-in sensors on participants' own phones also were used to indicate location and to quantify the sensory environment (e.g., ambient noise and light levels). Data fidelity was monitored to evaluate feasibility of the methods, and participant acceptability was assessed via an end-of-study survey. RESULTS Self-report data were obtained on a mean of 88.9% (24.9/28) of assigned days (SD = 22.4%) and at a mean of 68.9% (77.2/112) of assigned moments (SD = 24.5%). Data from the wearable biosensor were obtained for a mean of 18.7 hours per day worn (SD = 2.3 hours), with participants on average wearing the sensor on 20.3 days (SD = 9.9). Fidelity of obtaining objective data from phone sensors on the sensory environment and other environmental conditions was highly variable, with these data obtainable from 5 to 22/30 (16.7%-73.3%) of participants' own phones. Most participants (63.3%-100%) responded with at least "somewhat agree" to questions about acceptability of the study methods. However, 5 to 7/30 (16.7%-23.3%) patients indicated difficulties with burden and remembering to wear the sensor. Almost all participants (29/30, 96.7%) agreed that they would want information about when a migraine might occur. CONCLUSIONS A contemporary data sampling approach comprising ambulatory sensors and real-time reporting appears to be acceptable to most youth with migraine in this study. Reliability of acquiring some data sources from participants' own phones, however, was suboptimal. Further refining these data sampling methods may enable a novel means of predicting and preventing recurrences of migraine episodes in youth.
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Affiliation(s)
- Mark A Connelly
- Division of Developmental and Behavioral Health, Children's Mercy Kansas City, Kansas City, MO, USA
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Yamanaka G, Morichi S, Suzuki S, Go S, Takeshita M, Kanou K, Ishida Y, Oana S, Kawashima H. A Review on the Triggers of Pediatric Migraine with the Aim of Improving Headache Education. J Clin Med 2020; 9:jcm9113717. [PMID: 33228144 PMCID: PMC7699367 DOI: 10.3390/jcm9113717] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Revised: 11/14/2020] [Accepted: 11/16/2020] [Indexed: 12/18/2022] Open
Abstract
Although migraines are common in children and adolescents, they have a robustly negative impact on the quality of life of individuals and their families. The current treatment guidelines outline the behavioral and lifestyle interventions to correct common causative factors, such as negative emotional states, lack of exercise and sleep, and obesity; however, the evidence of their effectiveness is insufficient. To create a plan for disseminating optimal pediatric headache education, we reviewed the current evidence for factors correlated with migraine. We assessed three triggers or risk factors for migraines in children and adolescents: stress, sleep poverty, and alimentation (including diet and obesity). While there is a gradual uptick in research supporting the association between migraine, stress, and sleep, the evidence for diet-related migraines is very limited. Unless obvious dietary triggers are defined, clinicians should counsel patients to eat a balanced diet and avoid skipping meals rather than randomly limiting certain foods. We concluded that there is not enough evidence to establish a headache education plan regarding behavioral and lifestyle interventions. Clinicians should advise patients to avoid certain triggers, such as stress and sleep disorders, and make a few conservative dietary changes.
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10
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Connelly M, Bickel J. Primary Care Access to an Online Decision Support Tool is Associated With Improvements in Some Aspects of Pediatric Migraine Care. Acad Pediatr 2020; 20:840-847. [PMID: 31809810 DOI: 10.1016/j.acap.2019.11.017] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2019] [Revised: 11/18/2019] [Accepted: 11/28/2019] [Indexed: 12/30/2022]
Abstract
OBJECTIVE To evaluate whether primary care provider (PCP) access to an online decision support tool is associated with a change in evidence-based primary care medical management of pediatric migraine. METHODS In this prospective observational study, PCPs serving a target community were educated on the availability and use of an online clinical decision support tool that was developed to inform treatment of pediatric migraine. For 9 months before and after implementation of the decision tool, the proportions of children with migraine prescribed evidence-based and contraindicated medications by PCPs in the target region were monitored using electronic medical record query and statistically compared to these same proportions for patients in surrounding (control) regions. Rates of visits to the emergency department for migraine also were tracked pre- and postimplementation as an indirect measure of impact of the decision tool. Provider usage of the decision tool was monitored and summarized using web analytics. RESULTS Approximately half (56%) of target region PCPs used the online tool at least once over the project period. Relative to control regions and baseline trends, the proportion of children residing in the target region who were prescribed recommended abortive and preventive medications for treating migraine was statistically significantly higher following implementation of the tool. No significant changes to frequency of emergency care visits for migraine by youth in the target region were observed. CONCLUSIONS Availability to PCPs of an online decision support tool for pediatric migraine is associated with a modest change in some aspects of evidence-based medical care.
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Affiliation(s)
- Mark Connelly
- Division of Developmental and Behavioral Health (M Connelly), Children's Mercy Kansas City, Kansas City, MO.
| | - Jennifer Bickel
- Division of Neurology (J Bickel), Children's Mercy Kansas City, Kansas City, MO.
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Zhao YJ, Ho KH, Wong PS. Early clinical experience with a monoclonal antibody against the calcitonin gene-related peptide receptor in adolescents with migraine: A case series. PROCEEDINGS OF SINGAPORE HEALTHCARE 2020. [DOI: 10.1177/2010105820935465] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Management of migraine in adolescents poses a great challenge, as many of the approved pharmacological migraine preventive agents have age restrictions. Following favorable safety and efficacy reports of the new class agent calcitonin gene-related peptide (CGRP) monoclonal antibody for use in migraine prevention, there is growing interest in its application in pediatric migraine. We present here a case series detailing our experience of using erenumab, a CGRP monoclonal antibody, in six adolescent patients. Two patients had a reduction of at least 50% in the mean number of monthly migraine days, one patient reported subjective improvement, while three patients did not respond to the first dose of erenumab and discontinued treatment. One patient reported constipation associated with erenumab use. We speculate that CGRP monoclonal antibody could potentially be a viable option in adolescent patients with migraine. Further evidences that support efficacy and safety of erenumab in this group is needed.
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Affiliation(s)
- Yi Jing Zhao
- Department of Neurology, National Neuroscience Institute – Singapore General Hospital Campus, Singapore
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Charles JA. In Response to
Recommendations on the Use of Anti-CGRP Monoclonal Antibodies in Children and Adolescents. Headache 2020; 60:271-272. [DOI: 10.1111/head.13710] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- James A. Charles
- Headache Treatment Program for Children Adolescents and Adults at Holy Name Medical Center Teaneck NJ USA
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Connelly M, Sekhon S, Stephens D, Boorigie M, Bickel J. Enhancing Outpatient Dihydroergotamine Infusion With Interdisciplinary Care to Treat Refractory Pediatric Migraine: Preliminary Outcomes From the Comprehensive Aggressive Migraine Protocol (“CAMP”). Headache 2019; 60:101-109. [DOI: 10.1111/head.13685] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/01/2019] [Indexed: 12/17/2022]
Affiliation(s)
- Mark Connelly
- Division of Developmental and Behavioral Sciences Children’s Mercy Hospital Kansas City MO USA
| | - Subhjit Sekhon
- University of Missouri Kansas City School of Medicine Kansas City MO USA
| | - Dane Stephens
- University of Missouri Kansas City School of Medicine Kansas City MO USA
| | | | - Jennifer Bickel
- Division of Neurology Children’s Mercy Hospital Kansas City MO USA
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14
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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: 54] [Impact Index Per Article: 9.0] [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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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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Connelly M, Bickel J, Wingert T, Galemore C. The Headache Action Plan Project for Youth (HAPPY): School Nurses as Facilitators of System Change in Pediatric Migraine Care. NASN Sch Nurse 2018; 33:40-47. [PMID: 28777680 DOI: 10.1177/1942602x17719300] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Migraine is a common health problem in youth that is ranked highest for disability among neurological conditions and is one of the leading reasons for school absences. Children with migraines frequently are seen by the school nurse for care, sometimes before ever being seen by another healthcare provider for evaluation and treatment. As such, school nurses have the unique opportunity to provide education and resources to children with migraines and their family. This article provides information on the Headache Action Plan Program for Youth (HAPPY), a project involving the provision of live and online migraine education and management resources to school nurses, children, families, and primary care providers in an effort to improve migraine recognition and care in the community.
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Affiliation(s)
| | - Jennifer Bickel
- Medical Director and Chief of the Headache Section in Neurology, Kansas City, MO
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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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Rapoff MA, Connelly M, Bickel JL, Powers SW, Hershey AD, Allen JR, Karlson CW, Litzenburg CC, Belmont JM. Headstrong intervention for pediatric migraine headache: a randomized clinical trial. J Headache Pain 2014; 15:12. [PMID: 24580721 PMCID: PMC3996073 DOI: 10.1186/1129-2377-15-12] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2013] [Accepted: 01/02/2014] [Indexed: 11/13/2022] Open
Abstract
Background The purpose of this study was to evaluate the efficacy of a self-guided CD-ROM program (“Headstrong”) containing cognitive-behavioral self-management strategies versus an educational CD-ROM program for treating headaches, headache-related disability, and quality of life. Methods Participants were 35 children ages 7–12 years with migraine recruited from one university medical center and two children’s hospital headache clinics. Participants were randomly assigned to complete the Headstrong or educational control CD-ROM program over a 4-week period. Data on headache frequency, duration, and severity, migraine-related disability, and quality of life (QOL) were obtained at baseline, post-intervention, and 3-months post-intervention. Results At post-intervention, Headstrong resulted in lower severity (on a 10-point scale) than the control group by child report (5.06 ± 1.50 SD vs. 6.25 ± 1.92 SD, p = 0.03, ES = 0.7). At 3-months post-intervention, parents reported less migraine-related disability (on the PedMIDAS) in the Headstrong group compared to the control group (1.36 ± 2.06 SD vs. 5.18 ± 6.40 SD; p = 0.04, ES = 0.8). There were no other group differences at post treatment or at 3-months post-intervention. Conclusions When compared to an educational control, Headstrong resulted in lower pain severity at post-treatment and less migraine-related disability at 3-months post-intervention, by child and parent report respectively. Headache frequency and quality of life did not change more for Headstrong versus control. Additional research is needed on the Headstrong Program to increase its efficacy and to test it with a larger sample recruited from multiple centers simultaneously.
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Affiliation(s)
- Michael A Rapoff
- University of Kansas Medical Center, Department of Pediatrics, 3901 Rainbow Boulevard, Kansas City, KS 66160-7330, USA.
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Connelly M, Bickel J. Chronic daily headache in children and adolescents: science and conjecture. Pain Manag 2013; 3:47-58. [DOI: 10.2217/pmt.12.75] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
SUMMARY Chronic daily headache comprises a group of headache disorders in which headaches occur almost daily or continuously over several months. Although chronic daily headache is one of the most common chronic pain disorders in pediatrics, data on pathophysiological mechanisms and relative efficacy of treatments remain sparse. In this review, we aim to provide contemporary information on classification, epidemiology, etiology and treatment of pediatric chronic daily headache based on extant empirical data when available, or general consensus in the field when not.
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Affiliation(s)
- Mark Connelly
- Children’s Mercy Hospitals and Clinics, 2401 Gillham Road, Kansas City, MO 64108, USA
| | - Jennifer Bickel
- Children’s Mercy Hospitals and Clinics, 2401 Gillham Road, Kansas City, MO 64108, USA
- University of Missouri-Kansas City School of Medicine, 2411 Holmes Street, Kansas City, MO 64110, USA
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Abstract
The objective of this study was to examine potential trigger factors in migraine patients. A total of 126 migraine patients were interviewed about possible trigger factors for migraine. The most common trigger factors were emotional stress (79%), sleep disturbance (64%) and dietary factors (44%). Sleep and stress were significant trigger factors in patients with migraine with aura, whereas environmental factors were important trigger factors in patients with migraine without aura. Stress, sleep and environmental factors were important trigger factors in women and differed significantly from men. Trigger factors are frequent in migraine patients, and avoidance of such factors may result in a better control of the disorder.
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Cseh A, Farkas KM, Derzbach L, Muller K, Vasarhelyi B, Szalay B, Treszl A, Farkas V. Lymphocyte subsets in pediatric migraine. Neurol Sci 2012; 34:1151-5. [DOI: 10.1007/s10072-012-1218-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2012] [Accepted: 10/05/2012] [Indexed: 11/30/2022]
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Fraser IP, Han L, Han TH, Li CC, Hreniuk D, Stoch SA, Wagner JA, Linder S, Winner P. Pharmacokinetics and Tolerability of Rizatriptan in Pediatric Migraineurs in a Randomized Study. Headache 2012; 52:625-35. [DOI: 10.1111/j.1526-4610.2011.02069.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Al-Shimmery EK. Precipitating and relieving factors of migraine headache in 200 iraqi kurdish patients. Oman Med J 2011; 25:212-7. [PMID: 22043340 DOI: 10.5001/omj.2010.59] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2010] [Accepted: 03/30/2010] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVES To study the precipitating and relieving factors of migraine headache in a group of Iraqi Kurdish patients including the effect of fasting in Ramadan, and to estimate the percentage of family history of migraine. METHODS A series of 200 migraine cases from different parts of the Kurdistan region in the North of Iraq attending the out-patient Neurology clinic at Rizgary Teaching Hospital and a private Neurology clinic at Erbil City was carried out between October 2007 and May 2008 were reviewed. The precipitating factors and relieving factors for migraine headache were registered and tabulated to be compared with others. Case definition of migraine was based on the International Headache Society (IHS) criteria. RESULTS 33% of the patients were aged between 30-39 years, while 40.5% of patients experienced their first attack aged between 20-29 years. Stress or psychological upset was the commonest triggering factor (80%), followed by increasing physical activity (68%), change in weather (65.5%), and in relation to fasting (65%). Fasting in Ramadan was a triggering factor for headaches in 65% of patients. However, there was no significant association between the triggering factors with regards to sex difference. Relief of migraine in the studied sample was achieved using NSAIDs in 50% of patients, and sleep (45.5%). Hence, 61% of the study population had positive family history of migraine, 32.5% of them reported maternal history of migraine. CONCLUSION Psychological upset, stress and excessive physical activity were the commonest triggering factors of migraine headache, while NSAID was the commonest relieving factor of migraine in this population. Family history was present in 61% of migraine patients based mainly from maternal root.
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Affiliation(s)
- Ehsan K Al-Shimmery
- Neurology Unit, Department of Medicine, Hawler College of Medicine, Erbil, Iraq
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Hershey AD. Current approaches to the diagnosis and management of paediatric migraine. Lancet Neurol 2010; 9:190-204. [DOI: 10.1016/s1474-4422(09)70303-5] [Citation(s) in RCA: 107] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
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Charles JA, Von Dohln P. Outpatient Home-Based Continuous Intravenous Dihydroergotamine Therapy for Intractable Migraine. Headache 2010; 50:852-60. [DOI: 10.1111/j.1526-4610.2010.01622.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Headache and cognitive profile in children: a cross-sectional controlled study. J Headache Pain 2009; 11:45-51. [PMID: 19841863 PMCID: PMC3452186 DOI: 10.1007/s10194-009-0165-8] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2009] [Accepted: 10/01/2009] [Indexed: 11/05/2022] Open
Abstract
We investigated whether children affected by tension-type headache and migraine without aura, compared with a healthy control group that was matched by age, culturally and socioeconomically display a diverse intellectual functioning and have a separate “cognitive profile”. A cross-sectional study was conducted from January 2006 to November 2008 at “Sapienza University” in Rome. A total of 134 children were diagnosed as being affected by either migraine without aura (93) or tension-type headache (41). On the basis of our exclusion/inclusion criteria, we enrolled 82 of these 134 children, 63 of whom were affected by migraine without aura and 19 by tension-type headache. On entry, cognitive functions were assessed in both the affected subjects and the control group by the Wechsler Intelligence Scale for Children-revised. Significant differences were found between the headache and control groups in the mean total intelligence quotient and verbal intelligence quotient scores (p < 0.001). Significant negative correlations were found between the total intelligence quotient, verbal intelligence quotient, performance intelligence quotient and the frequency of attacks (r = −0.55 and p < 0.001, r = −0.61 and p < 0.001, r = −0.29 and p < 0.01, respectively), as well as between the total intelligence quotient score and the age at headache onset (r = 0.234, p < 0.05). Our results suggest that the cognitive profile of children affected by headache should be assessed at the first child neurology outpatient observation. From a therapeutic point of view, although within a normal range, the abilities most likely to be less brilliant in such children are verbal skills.
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