Butalbital and pediatric headache: stay off the downward path

A systematic review of high-frequency transcranial magnetic stimulation on motor cortex areas as a migraine preventive treatment

Background:

The results of high-frequency repetitive transcranial magnetic stimulation (rTMS) over the dorsolateral prefrontal cortex for migraine have been inconsistent. However, high-frequency rTMS over the motor cortex is a treatment that may be effective in relieving symptoms of migraine with a low risk of side effects.

Methods:

A systematic review of high-frequency rTMS over the brain motor cortex areas in human participants was conducted to assess efficacy in treating migraine. Articles that were not looking at migraine patients, stimulation over the left motor cortex, or were not in English were excluded. Nine articles representing eight experiments using high-frequency rTMS over the motor cortex areas for migraine in human participants were extracted from the databases of PubMed, PsycINFO, MedLine, CINAHL, and BioMed Central.

Results:

Two-hundred and seven of 213 patients completed treatment throughout all the studies examined. High-frequency rTMS over the motor cortex areas for migraine improved migraine frequency in seven of eight studies. Two of the eight studies were randomized controlled trials at low risk for biases and found high-frequency rTMS over the motor cortex areas effective in improving migraine frequency and severity. Other details of treatment prescription and symptoms were also examined.

Conclusion:

High-frequency rTMS over the motor cortex areas for migraine demonstrated efficacy as a migraine treatment, had minimal side effects, and should be further investigated.

Assessing evidence-based medicine and opioid/barbiturate as first-line acute treatment of pediatric migraine and primary headache: A retrospective observational study of health systems data

OBJECTIVES

To evaluate providers' use and predictors of evidence-based medicine or opioid/barbiturate as first-line acute treatment for children's initial presentation of acute migraine or primary headache.

METHODS

This retrospective, observational study utilized patient (children ages 6-17) and provider/encounter characteristics extracted from the patient's Electronic Health Record from 2008-2014 during an initial encounter for migraine or primary headache. The primary outcome was provider evidence-based medicine utilization; overall prescriptions and opioid/barbiturate prescriptions were also evaluated. Hierarchical linear modeling examined whether Level 1 (patient: Demographic, insurance type) and Level 2 (provider/encounter: Treatment setting/location, encounter diagnoses) characteristics influenced outcomes.

RESULTS

In all, 38,926 patients (56.7% female, mean age = 12.1) and 1617 providers were evaluated. Only 17.7% of patients were diagnosed with migraine; 16.1% received evidence-based medicine. Older children (OR = 1.07, p < 0.001), females (OR = 1.14, p < 0.001), and those diagnosed with migraine (OR = 4.71, p < 0.001) were more likely to receive evidence-based medicine. Among prescriptions, 15.8% were for opioids/barbiturates. Older children (OR = 1.14, p < 0.001) and those cared for in the emergency department/urgent care (OR = 2.02, p < 0.001) were at increased risk.

CONCLUSIONS

Demographics and migraine diagnosis are associated with evidence-based medicine and opioid/barbiturates. Primary care provides an opportunity to target provider interventions to enhance effective pediatric headache treatment.

Differences in Pediatric Headache Prescription Patterns by Diagnosis

BACKGROUND

Few studies have reported prescription patterns for headache medication.

OBJECTIVE

The aim was to present the rates of specific medication prescribed to pediatric patients diagnosed with migraine, tension-type headache (TTH), and new daily persistent headache (NDPH), as well as differences in those prescription patterns by diagnosis, age, and gender.

PATIENTS AND METHODS

A query using the i2b2 platform yielded 14,591 patients [migraine 10,547 (72.3%); TTH 3200 (21.9%); NDPH 844 (5.8%)] seen over a 3-year period, who were aged 4-17 years at the time of their visit and diagnosed with migraine, TTH, or NDPH.

RESULTS

Sumatriptan was the most frequently prescribed medication for migraine followed by amitriptyline. The most frequently prescribed medication for both TTH and NDPH was amitriptyline, followed by sumatriptan in TTH and by topiramate in NDPH. Age and gender differences were also found in prescription patterns of each of the diagnoses. The differences in prescription patterns found between the diagnoses, as well as age and gender differences found within the diagnoses, are discussed.

CONCLUSIONS

A wide range of medications are prescribed to children and adolescents with headache, with most medications prescribed for off-label use. As these medications are not Food and Drug Administration (FDA) approved for use in children and adolescents with headache, there is a need for large scale, randomized controlled trials to assess the efficacy of these medications.