Predictors of Short-Term Prognosis While in Pediatric Headache Care: An Observational Study

Anxiety and depressive symptoms and migraine-related outcomes in children and adolescents

OBJECTIVE

The objective of this study was to explore the longitudinal relationship between anxiety and depressive symptoms and migraine outcomes in children and adolescents.

BACKGROUND

Children and adolescents with migraine experience more anxiety and depressive symptoms than their peers without migraine, but it is unknown if these symptoms are associated with differential migraine outcomes.

METHODS

In this prospective clinical cohort study, children and adolescents aged 8.0-18.0 years with migraine completed headache questionnaires and validated measures of anxiety and depressive symptoms (Patient-Reported Outcomes Measurement Information System) at an initial consultation and at their first follow-up visit with a neurologist. Changes in monthly headache frequency and changes in migraine-related disability (Pediatric Migraine Disability Assessment) were tracked at each time point. The relationships between these migraine outcomes and anxiety and depressive symptoms were estimated using models controlling for sex, age, headache frequency, and treatment type.

RESULTS

There were 123 consenting participants. In models adjusted for age, sex, baseline disability score, and treatment type, baseline anxiety and depressive symptom levels were not significantly associated with change in headache frequency (for anxiety symptoms: β = -0.05, 95% confidence interval [CI] = -0.268 to 0.166, p = 0.639; for depressive symptoms: β = 0.14, 95% CI = -0.079 to 0.359, p = 0.209). Similarly, in models adjusted for age, sex, baseline headache frequency, and treatment type, the change in disability was not associated with baseline anxiety (β = -0.45, 95% CI = -1.69 to 0.78, p = 0.470), nor with baseline depressive symptom scores (β = 0.16, 95% CI = -1.07 to 1.40, p = 0.796). In post hoc exploratory analyses (N = 84 with anxiety and N = 82 with depressive symptom data at both visits), there were also no significant associations between change in mental health symptoms and change in headache frequency (for anxiety symptoms: β = -0.084, 95% CI = -0.246 to 0.078, p = 0.306; for depressive symptoms: β = -0.013, 95% CI = -0.164 to 0.138, p = 0.865). Similarly, the change in disability scores between visits was not related to the change in anxiety (β = 0.85, 95% CI = -0.095 to 1.78, p = 0.077) nor depressive symptom scores (β = 0.32, 95% CI = -0.51 to 1.15, p = 0.446).

CONCLUSION

Baseline anxiety and depressive symptom levels were not associated with longitudinal migraine outcomes and neither were longitudinal changes in anxiety and depressive symptom levels; this contradicts popular clinical belief that mental health symptoms predict or consistently change in tandem with migraine outcomes.

Association between clinician specialty and prescription of preventive medication for young adults with migraine: A retrospective cohort study

OBJECTIVE

We aimed to compare the prescribing patterns of preventive medications between pediatric and adult neurologists for young adults with migraine.

BACKGROUND

Although preventive medications are effective for adults with migraine, studies in children have failed to demonstrate similar efficacy. As a result, lifestyle modifications and non-pharmacological interventions are often emphasized in children. It is not known whether young adults are prescribed preventive medications at different rates according to whether they are cared for by an adult or pediatric neurologist.

METHODS

We performed a multicenter retrospective cohort analysis of patients with migraine aged 18-25 years who were seen by a pediatric or adult neurologist at Mass General Brigham Hospital between 2017 and 2021. The primary outcome was whether the patient received a prescription for any preventive medication during the study period.

RESULTS

Among the 767 included patients, 290 (37.8%) were seen by a pediatric neurologist. Preventive medications were prescribed for 131/290 (45.2%; 95% confidence interval [CI]: 39.5%, 51.0%) patients seen by a pediatric neurologist and 206/477 (43.2%; 95% CI: 39.0%, 47.7%) patients seen by an adult neurologist (p = 0.591). In the mixed effects logistic regression model, clinician specialty was not associated with preventive medication use (adjusted odds ratio [AOR] 1.20, 95% CI: 0.62, 2.31). Female sex (AOR 1.69, 95% CI: 1.07, 2.66) and number of visits during the study period (AOR 1.64, 95% CI: 1.49, 1.80) were associated with receiving preventive medication.

CONCLUSION

Approximately two fifths of young adults with migraine were prescribed preventive medications, and this proportion did not differ according to clinician specialty. Although these findings suggest that pediatric and adult neurologists provide comparable care, both specialties may be underusing preventive medications in this patient population.

Headache and Psychological Comorbidities: An Appraisal of the Evidence

BACKGROUND

It has been observed that there is a higher-than-expected risk of anxiety and depression in children with chronic headache and also an increased risk for the persistence of headache in patients with anxiety and depression.

OBJECTIVES

This review aims to identify and assess the relationships between primary headache disorders and comorbid emotional and psychological disorders.

METHODS

A targeted review of the literature was carried out.

RESULTS

The associations between the disorders are more pronounced in clinic patients, who may represent the severe end of the headache spectrum, but less clear in patients who were identified in population-based studies and who may represent the "average" child with headache or the "average" child with psychological disorders.

CONCLUSIONS

Understanding this bidirectional association of comorbid disorders is of great importance to offering a holistic biopsychosocial approach to the management of headache disorders in children and adolescents and in addressing the risks for and the co-existence of psychological comorbidities.

Burden of disease and lifestyle habits in adolescents and young adults prone to frequent episodic migraine: A secondary comparative analysis

The objective of this study was to assess the burden of disease and prevalence of lifestyle factors for adolescents and young adults with frequent episodic migraine. We conducted a secondary comparative analysis of data collected during two previous studies. Inclusion criteria for this analysis were age 15-35 years, 15 to 44 migraine episodes within 12 weeks, and completeness of Migraine Disability Assessment and lifestyle questionnaire data. Datasets of 37 adults (median age [interquartile range]: 25 [6]) and 27 adolescents (median age [interquartile range]: 15 [1]) were analyzed. 81% (n = 30) of adults reported severe disability (16% [n = 3] of adolescents; p < 0.001). Headache frequency (24 vs. 17 days; p = 0.005) and prevalence of regular analgesic use (60% [n = 22] vs. 18% [n = 5]; p = 0.002) were significantly higher in adults. In adults, sleep duration on weekdays was significantly lower (8.5 vs. 10 h; p < 0.001). Any consumption of caffeine tended to be higher in adolescents and alcohol consumption tended to be higher in adults (p > 0.05). This study underlines the importance of educating adolescents and young adults with migraine about lifestyle habits that are likely to interfere with the condition.

Predicting quality of life outcomes in children with migraine

INTRODUCTION

Several studies have shown that the response of children with migraine to medications is suboptimum and inferior to the response reported in adults, despite the similar pathogenesis and biological mechanisms. The poor response may be related to the significant differences that make assessment and treatment of children with migraine more challenging than in adults.

AREAS COVERED

The purpose of this review is to discuss the whole process of assessment of children with migraine, the necessary skills for eliciting the clinical features, making the correct diagnosis and exploring lifestyle issues, co-morbid conditions (psychological and physical) and social influences on disease presentations. Also, to establish and address peculiarities of migraine in children that would enable clinicians to advise on lifestyle modifications, co-morbid conditions and the correct choice of treatment options including non-pharmacologic therapies and medications.

EXPERT OPINION

The choice of treatment should be based on an assessment of each individual child taking into account, age, gender, pubertal status, body weight, comorbid disorders and family history. Also considering the profile of migraine episodes, frequency, duration, associated symptoms and effects of nausea and vomiting. Using the appropriate medications in appropriate dosage, formulation and route and timing of administration may improve adherence to treatment and outcome.

Acute and chronic management of posttraumatic headache in children: A systematic review

OBJECTIVES

The goal of this paper is to provide a compilation of the evidence for the treatment of posttraumatic headache (PTH) in the pediatric population. Headache features and timing of therapy were considered.

BACKGROUND

Headache is the most common symptom following mild traumatic brain injury (mTBI), affecting more than 80% of children and adolescents. It is unclear whether treatment for PTH should be tailored based on headache characteristics, particularly the presence of migraine features, and/or chronicity of the headache.

METHODS

Systematic literature searches of PubMed, Embase, Scopus, and Cochrane databases (1985-2021, limited to English) were performed, and key characteristics of included studies were entered into RedCAP^® (Prospero ID CRD42020198703). Articles and conference abstracts that described randomized controlled trials (RCTs), cohort studies, retrospective analyses, and case series were included. Participants included youth under 18 years of age with acute (<3 months) and persistent (≥3 months) PTH. Studies that commented on headache improvement in response to therapy were included.

RESULTS

Twenty-seven unique studies met criteria for inclusion describing abortive pharmacologic therapies (9), preventative pharmacotherapies (5), neuromodulation (1), procedures (5), physical therapy and exercise (6), and behavioral therapy (2). Five RCTs were identified. Studies that focused on abortive pharmacotherapies were completed in the first 2 weeks post-mTBI, whereas other treatment modalities focused on outcomes 1 month to over 1-year post-injury. Few studies reported on migrainous features (7), personal history of migraine (7), or family history of migraine (3).

CONCLUSIONS

There is limited evidence on the timing and types of therapies that are effective for treating PTH in the pediatric population. Prospective studies that account for headache characteristics and thoughtfully address the timing of therapies and outcome measurement are needed.

National Trends in Pediatric Headache and Associated Functional Limitations

Objective. Frequent or severe headaches are associated with school absenteeism and functional limitation in children, but trends in headache prevalence are uncertain. We used nationally representative data to describe trends in pediatric headache prevalence in the United States, and to evaluate whether headache has remained consistently associated with functional limitations among school-age children. Methods. We analyzed data on children age 5 to 17 years in the 2007 to 2015 National Health Interview Surveys. Caregivers reported whether each child experienced frequent or severe headache in the past 12 months. Weighted proportions and multivariable regression were used to estimate headache prevalence over the study period and associations between headache and measures of functional limitation. Results. The analysis included 57 272 children (mean age = 11 years; 52% female). Frequent or severe headache was reported for 6% of children, with no discernable trend over the study period. On multivariable Poisson regression, headache became more strongly associated with school absenteeism over time. In 2007, frequent or severe headache was associated with a 70% increase in the number of missed school days (incidence risk ratio [IRR] = 1.70; 95% confidence interval [CI] = 1.50-1.91; P < .001), whereas by 2015, headache was associated with a 139% increase in the number of missed school days (IRR = 2.39; 95% CI = 2.02-2.83; P < .001). Conclusion. Though the prevalence of frequent or severe headache in school-age children did not change in 2007 to 2015, headache became more strongly associated with school absenteeism, highlighting the need for improved management of patients with headaches to prevent negative impact on school performance and functional status.

Further Evidence that Onabotulinum Toxin is a Viable Treatment Option for Pediatric Chronic Migraine Patients

Introduction Chronic migraine is particularly devastating. It affects school work, extracurricular activities, and quality of life, including relationships with other family members, and can also influence the mental health of both the migraineurs and family members. According to the International Classification of Headache Disorders, 3rd edition (ICHD-3), chronic migraine is defined as 15 or more headache days per month for greater than three months, where at least on eight days per month, there are features of migraine headache. Although botulinum toxin type A (BoNTA) has been proven effective for treating chronic migraine in adults, little literature exists about its use in children. Here, we present the treatment response in children with chronic migraines treated with BoNTA at our institutions Duke and State University of New York (SUNY) Upstate. Method A retrospective analysis of 30 adolescent migraineurs who met ICHD-3 criteria for chronic migraine were treated with BoNTA injection according to the standardized adult protocol. Descriptive statistics and paired t-tests were performed. A total of 185 units of botulinum toxin were injected intramuscularly per patient, as in addition to the standard 31 sites for a total of 155 units, an additional 30 units were given in areas that were felt to provide further benefit. Results Participants (n=30) were 16.5 ± 1.83 years old. The headaches were precipitated by trauma in seven cases. All had failed standard pharmacotherapy, including amitriptyline and topiramate. An average of 2.47 ± 1.6 BoNTA injection cycles was performed. Migraine severity decreased significantly from 7.47 ± 1.89 on a 10-point scale to 4.34 ± 3.02 (p<.001). Additionally, headache frequency improved from 24.4 ± 7.49 painful days per month to 14.8 ± 12.52 painful days per month (p<.001). One patient developed nausea related to injections; all others tolerated it well, with no side effects. Discussion BoNTA injection was a safe and effective therapy for chronic migraine in our cohort of children recalcitrant to medical therapy. Further research with multi-centered, double-blinded, randomized, placebo-controlled trials is warranted to evaluate the long-term safety and efficacy in this population.