1
|
Shah S, Calderon MD, Crain N, Pham J, Rinehart J. Effectiveness of onabotulinumtoxinA (BOTOX) in pediatric patients experiencing migraines: a randomized, double-blinded, placebo-controlled crossover study in the pediatric pain population. Reg Anesth Pain Med 2020; 46:41-48. [PMID: 33106278 DOI: 10.1136/rapm-2020-101605] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Revised: 09/11/2020] [Accepted: 09/15/2020] [Indexed: 11/03/2022]
Abstract
INTRODUCTION OnabotulinumtoxinA (OBTA) is approved for treating chronic headaches and migraines in adults, but there is limited scientific literature on the outcomes in pediatric patients. The aim of this study was to determine if subjects treated with OBTA reported a statistically significant improvement in the primary features (frequency, intensity, duration and disability scoring) associated with migraines compared with placebo at follow-up visits. METHODS After obtaining approval by the appropriate local (HS# 2016-3108) and federal institutions, the principal investigator enrolled candidates aged 8 to 17 years old diagnosed with chronic migraines (at least 6 months), and 15 or more headache days in a 4-week baseline period. This randomized control trial consisted of two phases: double-blind and open-label for the first two and last two sets of treatments, respectively. Subjects were randomly assigned to receive a treatment protocol-155 units at 31 injection sites-in 3-month intervals and follow-up visits every 6 weeks. Non-parametric testing (Wilcoxon signed-rank test) was performed using widely available open-source statistical software ('R'). RESULTS From February 2017 to November 2018, 17 subjects presented for a screening visit; 15 met eligibility criteria. Subjects that received OBTA reported a statistically significant decrease from the following baseline values compared with placebo 6-week post-treatment compared with placebo: frequency (20 (7 to 17) vs 28 (23 to 28); p=0.038), intensity (5 (3 to 7) vs 7 (5 to 9); p=0.047), and PedMIDAS (Pediatric Migraine Disability Score) (3 (2 to 4) vs 4 (4 to 4); p=0.047). There was no statistically significant difference in the duration (10 (2 to 24) vs 24 (4 to 24); p=0.148) of migraines between the two groups. DISCUSSION OnabotulinumtoxinA showed a statistically significant decrease in frequency and intensity of migraines compared with placebo. No adverse effects or serious adverse events related to the use of OBTA were reported. In the future, we aim to evaluate the specific nature of migraines, for example, quality/location of pain presented during an initial consult to predict the likelihood of OBTA being a truly effective modality of pain management for pediatric migraineurs. TRIAL REGISTRATION NUMBER NCT03055767.
Collapse
Affiliation(s)
- Shalini Shah
- Department of Anesthesiology & Perioperative Care, University of California Irvine Health, Orange, CA, 92868
| | - Michael-David Calderon
- Department of Anesthesiology & Perioperative Care, University of California Irvine Health, Orange, CA, 92868
| | - Nikhil Crain
- Department of Anesthesiology & Perioperative Care, University of California Irvine Health, Orange, CA, 92868
| | - Jason Pham
- Department of Anesthesiology & Perioperative Care, University of California Irvine Health, Orange, CA, 92868
| | - Joseph Rinehart
- Department of Anesthesiology & Perioperative Care, University of California Irvine Health, Orange, CA, 92868
| |
Collapse
|
2
|
Recober A, Patel PB, Thibault DP, Hill AW, Kaiser EA, Willis AW. Sociodemographic Factors Associated With Hospital Care for Pediatric Migraine: A National Study Using the Kids' Inpatient Dataset. Pediatr Neurol 2019; 91:34-40. [PMID: 30578049 DOI: 10.1016/j.pediatrneurol.2017.10.023] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2017] [Revised: 10/20/2017] [Accepted: 10/30/2017] [Indexed: 11/30/2022]
Abstract
BACKGROUND Although migraine often starts in childhood or adolescence, hospital care for migraine in children is not well described. We examined patient and hospital characteristics associated with hospital care for migraine among children in the United States. METHODS We queried the Kids' Inpatient Database (2003 to 2009) for hospitalizations of children aged 3-20. Sociodemographic and hospital characteristics were compared between hospitalizations for migraine and for other common medical conditions. Multivariate logistic regression models estimated the associations between patient, hospital, and socioeconomic characteristics and inpatient migraine care. RESULTS We identified 11,696 pediatric migraine hospitalizations, the majority (68.7%) occurring at teaching hospitals, involving a female (68.8%) child, ages 13-20 (71%, mean age: 14.6 years). As compared to the overall inpatient sample, migraine hospitalizations were less likely to involve children who were Black (adjusted odds ratio [AOR] 0.54, 95% confidence interval [CI] 0.49 to 0.60), Hispanic (AOR = 0.58, 95% CI 0.50 to 0.68), or Asian (AOR = 0.42, 95% CI 0.32 to 0.55), and more likely to involve females (AOR = 1.49, 95% CI 1.40 to 1.59). Migraine inpatients were more likely to live in higher income postal ZIP code areas (versus lowest ZIP code income quartile: AOR = 1.32, 95% CI 1.18 to 1.48). The average length of stay for migraine was 2.54 (SEM 0.6) days. CONCLUSIONS Children who are hospitalized for migraines have distinct sociodemographic characteristics and a short length of stay. Understanding the reasons for these variations will inform the design of interventions aimed at reducing the need for pediatric migraine hospitalization.
Collapse
Affiliation(s)
- Ana Recober
- Department of Neurology, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania; Division of Neurology, Children's Hospital of Pennsylvania, Philadelphia, Pennsylvania; Pediatric Neurology Health Services Research Group, Department of Neurology, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
| | - Payal B Patel
- Department of Neurology, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania; Division of Neurology, Children's Hospital of Pennsylvania, Philadelphia, Pennsylvania
| | - Dylan P Thibault
- Department of Neurology, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania; Department of Neurology, University of Pennsylvania School of Medicine, Translational Center of Excellence for Neuroepidemiology and Neurology Outcomes Research, Philadelphia, Pennsylvania
| | - Andrew W Hill
- Department of Neurology, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
| | - Eric A Kaiser
- Department of Neurology, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
| | - Allison W Willis
- Department of Neurology, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania; Pediatric Neurology Health Services Research Group, Department of Neurology, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania; Department of Neurology, University of Pennsylvania School of Medicine, Translational Center of Excellence for Neuroepidemiology and Neurology Outcomes Research, Philadelphia, Pennsylvania; Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania; Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, Pennsylvania.
| |
Collapse
|
3
|
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.
Collapse
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
| |
Collapse
|
4
|
Abstract
While it has been established that headaches in the pediatric age group are relatively common, the characterization of headache disorders and their treatment in this group has historically been limited. Due to the paucity of controlled studies on prophylaxis of the primary headache disorders in children, the diagnosis of migraine often rests on criteria similar to those used in adults. Data from adult studies are often extrapolated and applied to the pediatric patient. Although it appears that many prophylactic agents are safe, well tolerated and efficacious in children, currently only topiramate is FDA-approved for use in patients 12 years and over. As a result, despite often experiencing significant disability, many children who present to their physician with migraines do not receive preventive therapy. One-third of adolescents meet the criteria for warranting prophylactic therapy, yet few are offered a preventative medication. Moreover, controlled clinical trials investigating the use of both abortive and prophylactic medications in children have suffered from high placebo response rates. A diverse group of medications are used to prevent migraine attacks, including antidepressants, antiepileptics, antihistamines and antihypertensive agents, yet there still remains a serious lack of controlled studies on the pharmacological treatment of pediatric migraine.
Collapse
Affiliation(s)
- Joanne Kacperski
- Division of Neurology, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave-MLC 2015, Cincinnati, OH, 45229-3039, USA,
| |
Collapse
|
5
|
Abstract
While headaches in children are quite common, the study and characterization of headache disorders in the pediatric age group has historically been limited. In the absence of controlled studies on prophylactic treatment of the primary headache disorders in this age group, the diagnosis of childhood migraine rests on criteria similar to those in adults. Data from adult studies are often extrapolated and applied to children as well. Although it appears that many preventive agents are safe in children, none are currently FDA-approved for this age group. As a result, despite experiencing significant disability, the vast majority of children who present to their physician with migraine headache do not receive prophylactic therapy. Furthermore, controlled clinical trials investigating the use of both abortive and preventive medications in children have suffered from high placebo response rates. The shorter duration of headaches and other characteristic features seen in children are such that designing randomized controlled trials in this age group is more problematic and limiting. As such, treatment practices vary widely, even among specialists, due to the absence of evidence-based guidelines from clinical trials.
Collapse
|
6
|
Abstract
Migraine headache is a common problem among children and adolescents that is now recognized as a significant and often debilitating condition in this population. Improved recognition and management of pediatric migraine in primary care is necessary, as there is a knowledge gap in understanding the unique features of this condition and a general reluctance to treat children.
Collapse
Affiliation(s)
- Alicia Harding
- Alicia Harding is a nurse practitioner at Children's Medical Center, Dallas, Tex. Lynn Clark is a nurse practitioner, Manager Pain Management and Palliative Care at Children's Medical Center, Dallas, Tex
| | | |
Collapse
|
7
|
Utterback G, Zacharias R, Timraz S, Mershman D. Butterbur extract: Prophylactic treatment for childhood migraines. Complement Ther Clin Pract 2014; 20:61-4. [DOI: 10.1016/j.ctcp.2012.04.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2012] [Accepted: 04/25/2012] [Indexed: 12/30/2022]
|
8
|
Topiramate and propranolol for prophylaxis of migraine. Indian J Pediatr 2013; 80:920-4. [PMID: 23412986 DOI: 10.1007/s12098-013-0976-0] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2012] [Accepted: 01/21/2013] [Indexed: 10/27/2022]
Abstract
OBJECTIVE To compare efficacy and safety of topiramate (TPM) and propranolol for migraine prophylaxis in children. METHODS In a parallel single-blinded randomized clinical trial, 5-15 y-old referred migraineurs to Pediatric Neurology Clinic of Shahid Sadoughi Medical Sciences University, Yazd, Iran from May through October 2011, were evaluated. Patients were distributed into two groups, 50 of whom were treated with 3 mg/kg/d of topiramate (TPM) and another group of 50, were treated with 1 mg/kg of propranolol for 3 mo. Primary endpoints were efficacy in reduction of monthly frequency, severity, duration and headache related disability. Secondary outcome was clinical side effects. RESULTS Fifty two girls and 48 boys with mean age of 10.34 ± 2.31 y were evaluated. Monthly frequency, severity and duration of headache decreased with TPM, from 13.88 ± 8.4 to 4.13 ± 2.26 attacks, from 6.32 ± 1.93 to 2.8 ± 2.12, and from 2.36 ± 1.72 to 0.56 ± 0.5 h, respectively. Monthly frequency, severity and duration of headache also decreased with propranolol from 16.2 ± 6.74 to 8.8 ± 4.55 attacks, from 6.1 ± 1.54 to 4.8 ± 1.6 and from 2.26 ± 1.26 to 1.35 ± 1.08 h, respectively. Pediatric Migraine Disability Assessment score reduced from 31.88 ± 9.72 to 9.26 ± 7.21 with TPM and from 33.08 ± 8.98 to 23.64 ± 9.88 with propranolol. Transient mild side effects were seen in 18 % of TPM and in 10 % of propranolol (P = 0.249) groups. CONCLUSIONS Topiramate is more effective than propranolol for pediatric migraine prophylaxis.
Collapse
|
9
|
Abstract
Migraines are a common complaint in children and can cause a significant burden to both the child and their families, with a substantial loss in both school and work days, as well as having negative effects on the child’s self-esteem and peer relations. It has become clear that migraine-specific medications are needed in this population of patients and their use may result in a significant improvement of the child’s headaches and quality of life. Rizatriptan benzoate (Maxalt®) is a selective 5-hydroxytryptamine/serotonin1B/1D (5-HT1B/1D ) agonist that was approved by the US FDA in 1998 for the acute treatment of migraine attacks in adults. Despite having been widely used in the pediatric population, rizatriptan was most recently approved in December 2011 for pediatric use in children aged 6–17 years. The advantage of rizatriptan over some other triptans is its rapid onset of action, which is thought to be beneficial in the generally shorter migraine attacks of children when compared with adults. It may also be an appealing choice for young children because it comes in an orally disintegrating form for those who may have difficulty in swallowing tablets or who have significant gastrointestinal complaints accompanying their headaches, including nausea, vomiting and abdominal pain.
Collapse
Affiliation(s)
- Joanne Kacperski
- Department of Neurology, Cincinnati Children’s Hospital Medical Center, 3333 Burnet Avenue – MLC 2015 Cincinnati, OH 45229, USA
| | - Hope L O’Brien
- Department of Neurology, Cincinnati Children’s Hospital Medical Center, 3333 Burnet Avenue – MLC 2015 Cincinnati, OH 45229, USA
| |
Collapse
|