The pathophysiology of primary headache

Evaluation of Pain Syndromes, Headache, and Temporomandibular Joint Disorders in Children

After a thorough review of the history and presentation of a child's facial pain, a targeted head and neck examination is critical to the appropriate diagnosis of facial pain and temporomandibular joint disorders. It is critical to distinguish between the structural (trauma, degenerative disease, and tumor) and nonstructural (neurogenic, myogenic, and psychological) causes of pain, which will allow for incorporation of appropriate strategies of medical, psychological, dental, and surgical therapies.

Topiramate for Migraine Prophylaxis in Pediatric Patients

Objective: To evaluate the currently published data pertaining to the efficacy and safety of topiramate for prophylaxis of classic and common migraine in pediatric patients. Data Sources: The literature was identified via PubMed (through April 2013) and Iowa Drug Information System (through April 2013). References from identified articles were also reviewed. Study Selection and Data Extraction: Data were included from studies of efficacy and safety in pediatric patients experiencing migraine (with or without aura), as defined by the International Headache Society. Studies including patients with more specific types of migraine, such as basilar migraine, were excluded. Data Synthesis: Eight publicatons were identified, including 3 randomized controlled trials (RCTs), a subgroup analysis, and 4 observational studies. These studies reported a decrease in headache frequency ranging from 63% to 100% for doses of 100 mg/d and 65% for 200 mg/d. Response to therapy, defined as ≥50% reduction in migraine rate, was also reported in 83% to 95% of patients receiving topiramate. Topiramate is generally well tolerated. Adverse effects were dose related and included paresthesias, weight loss, and cognitive adverse effects. Conclusion: Topiramate is an effective and well-tolerated prophylactic therapy for use in pediatric migraine patients. Doses of 100 and 200 mg/d (1.47-2.0 mg/kg/d) effectively decrease the frequency of migraine headaches, with 100 mg/d providing optimal benefit-to-risk ratio. Additional randomized, double-blind, placebo-controlled studies are needed to determine the impact of the drug on quality-of-life outcomes, such as school function, and migraine severity and duration.

Changing Physician Knowledge, Attitudes, and Beliefs About Migraine: Evaluation of a New Educational Intervention

OBJECTIVE

Use a presurvey of primary care providers (PCPs) enrolled in a continuing medical education (CME) program on headache management to ascertain their existing knowledge, attitudes, and beliefs regarding migraine and use a postsurvey to determine the extent to which the CME program has brought participant knowledge, attitudes, and skills closer to conformance with best evidence.

BACKGROUND

Migraine is a common and debilitating condition, which PCPs may not always manage satisfactorily. In an effort to improve management, the American Headache Society has developed a CME program called BRAINSTORM that encourages PCPs to adopt the US Headache Consortium Guidelines for headache care.

METHODS

A 20-item questionnaire was developed that covered the essential elements of migraine care. The questionnaire was administered before and after a BRAINSTORM presentation to 254 consenting primary care clinicians attending a medical meeting at 1 of 6 sites. A control group of 112 comparable physicians who did not attend the presentation completed the same questionnaire. Prepresentation scores of attendees were compared to scores of nonattendees to assess the generalizability of results. Prepresentation scores on selected questions were used to assess participant baseline knowledge, attitudes, and beliefs. Pre- and postpresentation scores for attendees at all sites were compared using the Mantel-Haenszel statistic to assess the effectiveness of the BRAINSTORM CME. Pre- and postpresentation scores were compared by site using the Breslow-Day test to evaluate any differential impact based on CME location.

RESULTS

Prepresentation scores of attendees and nonattendees were found to be similar. No significant difference in performance was noted across sites. A chi-square analysis revealed a statistically significant difference between pre- and postpresentation scores for 16 of the test's 20 questions. In the pretest, all participants scored <66% on 2 questions related to prevalence, impact, and pathophysiology of migraine, 2 questions pertaining to history taking/physical examination, and 3 migraine management questions. Attendee scores improved to >66% posttest on all except 2 questions related to prevalence, impact, and pathophysiology of migraine.

CONCLUSION

Our results indicate that PCPs need to acquire greater understanding about the epidemiology and pathophysiology of migraine and may require guidance in history taking and physical examination of migraine patients. Improvement in scores posttest confirms that the BRAINSTORM program has a significant immediate impact on the knowledge, beliefs, and attitudes of participants. The program could be strengthened to improve emphasis in some areas where posttest scores showed no improvement.