Topiramate for migraine prevention in children: a randomized, double-blind, placebo-controlled trial

Preventive Medications in Pediatric Migraine: A Network Meta-Analysis

Importance

Pediatric migraine substantially impacts quality of life and academic performance among children and adolescents. Understanding the efficacy and safety of pharmacological interventions for migraine prophylaxis in this population is crucial for developing effective treatment strategies.

Objective

To conduct a comprehensive network meta-analysis to evaluate the efficacy and safety associated with pharmacological treatments for pediatric migraine prophylaxis among pediatric patients with a migraine diagnosis and assess interventions involving various oral pharmacological interventions compared with each other and placebo.

Data Sources

PubMed, Embase, and SCOPUS were searched for publications up to September 2023. Search terms and indexing were chosen to encompass relevant studies, focusing on randomized clinical trials in pediatric migraine prophylaxis.

Study Selection

Inclusion criteria targeted randomized clinical trials involving pediatric patients with migraine. Studies were selected based on their examination of oral pharmacological interventions. The search yielded an initial 9162 citations.

Data Extraction and Synthesis

Data extraction adhered to Preferred Reporting Items for Systematic Reviews and Meta-Analyses reporting guidelines. Five investigators independently extracted study data into a spreadsheet in duplicate. Study-level estimates were calculated, employing a random-effects model for primary and secondary outcomes due to identified heterogeneity. Data analysis was conducted from December 2023 to March 2024.

Main Outcomes and Measures

The primary outcome was migraine frequency (number of attacks per month). Secondary outcomes included a 50% or greater responder rate, headache duration, headache intensity, and disability (assessed by pediatrics migraine-specific disability tool). Adverse events were also evaluated.

Results

The analysis incorporated 45 trials with 3771 participants. Compared with placebo, pregabalin (ratio of means [RoM], 0.38; 95% CI, 0.18-0.79) and topiramate with vitamin D3 (RoM, 0.44; 95% CI, 0.30-0.65) were associated with reduction in migraine frequency. Flunarizine (RoM, 0.46; 95% CI, 0.26-0.81), levetiracetam (RoM, 0.47; 95% CI, 0.30-0.72), riboflavin (RoM, 0.50; 95% CI, 0.32-0.77), cinnarizine (RoM, 0.64; 95% CI, 0.46-0.88), topiramate (RoM, 0.70; 95% CI, 0.55-0.89), and amitriptyline (RoM, 0.73; 95% CI, 0.54-0.97) were also associated with reduction in migraine frequency, but these findings were drawn from individual studies. For the 50% or greater responder rate, flunarizine and α-lipoic acid (risk ratio [RR], 8.73; 95% CI, 2.44-31.20), flunarizine (RR, 4.00; 95% CI, 1.38-11.55), pregabalin (RR, 1.88; 95% CI, 1.13-3.14), and cinnarizine (RR, 1.46; 95% CI, 1.04-2.05) were associated with significantly greater effectiveness than placebo. Compared with placebo, propranolol and cinnarizine (RoM, 0.45; 95% CI, 0.28-0.72), pregabalin (RoM, 0.57; 95% CI, 0.33-0.96), valproate (RoM, 0.60; 95% CI, 0.49-0.72), levetiracetam (RoM, 0.62; 95% CI, 0.50-0.77), and cinnarizine (RoM, 0.64; 95% CI, 0.54-0.76) were significantly associated with reduction in headache intensity. However, no treatments were associated with significant improvements in quality of life or reduction of the duration of migraine attacks. Adverse events were higher with amitriptyline (RR, 3.81; 95% CI, 1.41-10.32), topiramate (RR, 4.34; 95% CI, 1.60-11.75), and valproate (RR, 5.93; 95% CI, 1.93-18.23) compared with placebo.

Conclusions and Relevance

In this network meta-analysis of randomized clinical trials, topiramate and pregabalin were associated with reduction in headache frequency and intensity. Although there were also other drugs that showed statistically significant results (flunarizine, riboflavin, amitriptyline, and cinnarizine), more studies were required for a robust conclusion. None of the drugs were associated with improved quality of life or attack duration, underscoring the need for further research to develop more comprehensive treatment strategies and explore the potential of combination therapies, especially those involving vitamins. Future studies should focus on validating these findings and expanding the treatment landscape for pediatric migraine management.

Unsatisfactory response to acute medications does not affect the medication overuse headache development in pediatric chronic migraine

BACKGROUND

Chronic migraine (CM) negatively impacts the quality of life of 2 to 4% of pediatric patients. In adults, CM is frequently linked to medication overuse headache (MOH), but there is a much lower prevalence of MOH in children. A suboptimal response to acute therapies may lead to their reduced use, thus preventing MOH development in children and adolescents. The frequency of patients with CM who do not respond to acute therapies was examined in the present study. We investigated whether the prevalence of MOH was different between responders and non-responders. We also examined whether patients receiving prophylactic therapy had an improved response to acute therapy. Finally, we investigated if there was a difference in the frequency of psychiatric comorbidities between responders and non-responders.

METHODS

We retrospectively analysed clinical data of all chronic pediatric migraineurs under the age of 18 referred to the Headache Centre at Bambino Gesù Children Hospital in June 2021 and February 2023. ICHD3 criteria were used to diagnose CM and MOH. We collected demographic data, including the age at onset of migraine and the age of the CM course. At baseline and after 3 months of preventive treatment, we evaluated the response to acute medications. Neuropsychiatric comorbidities were referred by the children's parents during the first attendance evaluation.

RESULTS

Seventy patients with CM were assessed during the chosen period. Paracetamol was tried by 41 patients (58.5%), NSAIDs by 56 patients (80.0%), and triptans by 1 patient (1.4%). Fifty-one participants (73%) were non-responder to the abortive treatment. The presence of MOH was detected in 27.1% of the whole populations. Regarding our primary aim, MOH was diagnosed in 29% of non-responder patients and 22% of responders (p > 0.05). All patients received preventative treatment. After 3 months of preventive pharmacological therapy, 65.4% of patients who did not respond to acute medications achieved a response, while 34.6% of patients who were non-responder remain non-responder (p < 0.05). Prophylactic therapy was also effective in 69% of patients who responded to acute medication (p < 0.05). Psychiatric comorbidities were detected in 68.6% of patients, with no difference between responders and non-responders (72.2% vs. 67.3%; p = 0.05).

CONCLUSIONS

Despite the high prevalence of unresponsiveness to acute therapies in pediatric CM, it does not act as a protective factor for MOH. Moreover, responsiveness to acute drugs is improved by pharmacological preventive treatment and it is not affected by concomitant psychiatric comorbidities.

High Dosage Omega-3 Fatty Acids Outperform Existing Pharmacological Options for Migraine Prophylaxis: A Network Meta-Analysis

Migraine is a highly prevalent neurologic disorder with prevalence rates ranging from 9% to 18% worldwide. Current pharmacologic prophylactic strategies for migraine have limited efficacy and acceptability, with relatively low response rates of 40% to 50% and limited safety profiles. Eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) are considered promising therapeutic agents for migraine prophylaxis. The aim of this network meta-analysis (NMA) was to compare the efficacy and acceptability of various dosages of EPA/DHA and other current Food and Drug Administration-approved or guideline-recommended prophylactic pharmacologic interventions for migraine. Randomized controlled trials (RCTs) were eligible for inclusion if they enrolled participants with a diagnosis of either episodic or chronic migraine. All NMA procedures were conducted under the frequentist model. The primary outcomes assessed were 1) changes in migraine frequency and 2) acceptability (i.e., dropout for any reason). Secondary outcomes included response rates, changes in migraine severity, changes in the frequency of using rescue medications, and frequency of any adverse events. Forty RCTs were included (N = 6616; mean age = 35.0 y; 78.9% women). Our analysis showed that supplementation with high dosage EPA/DHA yields the highest decrease in migraine frequency [standardized mean difference (SMD): -1.36; 95% confidence interval (CI): -2.32, -0.39 compared with placebo] and the largest decrease in migraine severity (SMD: -2.23; 95% CI: -3.17, -1.30 compared with placebo) in all studied interventions. Furthermore, supplementation with high dosage EPA/DHA showed the most favorable acceptability rates (odds ratio: 1.00; 95% CI: 0.06, 17.41 compared with placebo) of all examined prophylactic treatments. This study provides compelling evidence that high dosage EPA/DHA supplementation can be considered a first-choice treatment of migraine prophylaxis because this treatment displayed the highest efficacy and highest acceptability of all studied treatments. This study was registered in PROSPERO as CRD42022319577.

Remote electrical neuromodulation (REN) wearable device for adolescents with migraine: a real-world study of high-frequency abortive treatment suggests preventive effects

Introduction

Migraine is a chronic neurological disease manifesting as attacks of disabling head pain and associated symptoms. Remote electrical neuromodulation (REN) is a non-pharmacological, prescribed, wearable device (Nerivio®). This device has been certified by the FDA for the acute and/or preventive treatment of migraine with or without aura in patients 12 years of age or older. The device is affixed to the user's arm during 45-min treatment sessions and is operated using a smartphone app. This study (NCT05769322) aims to evaluate whether frequent use of REN for the acute treatment of migraine in adolescents resulted in a reduction in monthly migraine treatment days (MMTD), as previously demonstrated in adults through a dedicated prevention clinical trial (NCT04828707).

Methods

The study included real-world prospective data from adolescent patients who used REN on at least 10 days every 28-day month, following the REN migraine prevention guideline of an every-other-day pattern. Additional requirements were at least three REN treatment days in each of the two subsequent months. The number of MMTD was used as a proxy measure for the number of monthly migraine days (MMD). The change in MMTD from the first month, taken as a "baseline," to each of the following months was used to evaluate the presence and size of potential migraine preventive benefits of REN in adolescents.

Results

A total of 83 adolescents were eligible for analysis. The users were 15.9 ± 1.3 years of age (mean ± SD), and 89% of them were female. The results demonstrated a substantial month-to-month reduction in the mean (±SD) number of REN treatment days from 12.6 (±3.2) MMTD in the first month to 9.0 (±4.8) MMTD in the second month (p < 0.001), and a further decrease to 7.4 (±4.2) MMTD in the third month (p < 0.001). This indicates an accumulative reduction of 5.2 (±4.8) mean REN MMTD from the first month to the third month of consecutive REN treatment. The users also reported consistent 2-h acute pain responses in at least 50% of their treated attacks, with 61.9% of the users reported experiencing pain relief, 24.5% reported pain freedom, 67.4% indicated relief in functional disability, and 41.3% reported complete freedom from functional disability.

Conclusion

The frequent use of REN among adolescents as an acute treatment for migraine attacks resulted in a decrease in the mean number of monthly treatment days in the subsequent months, suggesting that REN may have potential preventive benefits for migraine in this subpopulation.

A Narrative Review: Phentermine and Topiramate for the Treatment of Pediatric Obesity

The prevalence of pediatric obesity has increased exponentially over the past four decades. The American Academy of Pediatrics recently released updated clinical practice guidelines highlighting the importance of identifying pediatric obesity as a chronic disease. The guidelines support consideration of concurrent treatment with intensive lifestyle interventions, obesity pharmacotherapy, and bariatric surgery. The dramatic rise in pediatric obesity has spurred interest in utilizing obesity pharmacotherapy to support sustained weight reduction in pediatric cohorts, in the hopes of preventing the emergence of later-appearing, significant co-morbidities. Despite the enormous demand, the obstacles posed by performance of needed clinical trials in the pediatric population markedly limits available pharmacotherapy for the treatment of obesity in pediatrics. Currently, there are five medications approved by the Food and Drug Administration for use in youth with obesity. In 2022, the phentermine/topiramate (PHEN/TPM), once-daily, controlled-release, combination product received FDA approval, for the indication of chronic weight management, in youth with obesity, ages 12 years and older. The objectives of this narrative review are to: (1) Review the mechanism of action of phentermine and topiramate, (2) Summarize the safety and efficacy data of topiramate and phentermine use as both monotherapies and in combination, and (3) Discuss clinical practice guidelines and clinical implications, for the use of these agents in youths with obesity.

Medication-induced weight gain and advanced therapies for the child with overweight and obesity: An Obesity Medicine Association (OMA) Clinical Practice Statement 2022

Background

This Obesity Medicine Association (OMA) Clinical Practice Statement (CPS) details medication-induced weight gain and advanced therapies for the child with overweight or obesity.

Methods

The scientific information and clinical guidance in this CPS are based on scientific evidence, supported by the medical literature, and derived from the clinical perspectives of the authors.

Results

This OMA Clinical Practice Statement addresses medication-induced weight gain and advanced therapies for the child with overweight or obesity.

Conclusions

This OMA Clinical Practice Statement on medication induced-weight gain and advanced therapies for the child with overweight or obesity is an overview of current recommendations. These recommendations provide a roadmap to the improvement of the health of children and adolescents with obesity, especially those with metabolic, physiological, and psychological complications. This CPS also addresses treatment recommendations. This section is designed to help the provider with clinical decision making.

From the New Diagnostic Criteria to COVID-19 Pandemic Passing Through the Placebo Effect. What Have We Learned in the Management of Pediatric Migrane Over the Past 5 Years?

In 2018, the Food and Drug Administration (FDA) approval of anti-calcitonin gene-related peptide (CGRP) therapies for the treatment of migraine represented a milestone for the management of the disease in adults. On the contrary, the novelties in the field of pediatric migraine are inserted in a different scenario and still concern: (1) diagnostic criteria of the international classification of headache disorders-3 (ICHD-3) that show numerous limits of applicability in the developmental age; (2) the release of the results of the Childhood and Adolescent Migraine Prevention (CHAMP) study that raised doubts about the usefulness of traditional drugs for the treatment of pediatric migraine; (3) the Coronavirus disease 2019 (COVID-19) pandemic has put the spotlight on the importance of managing the psychological factors associated with the disease. In this mini review we discuss the most relevant news in pediatric migraine over the last 5 years.

Efficacy and Safety of Repetitive Intravenous Sodium Valproate in Pediatric Patients With Refractory Chronic Headache Disorders: A Retrospective Review

BACKGROUND

Chronic headache disorders can cause substantial disability and be treatment refractory. Often, these patients are excluded from clinical trials with leaving little evidence to guide treatment. In adults, divalproex sodium is an effective preventive migraine treatment.

METHODS

All pediatric patients admitted for first-time sodium valproate infusions to treat refractory, chronic migraine (CM), new daily persistent headache, or persistent headache attributed to head trauma from January 2017 to October 2020 were identified for review. Each patient underwent a standardized, 4-day protocol. A new preventive was started one week after discharge. Data on headache frequency, severity, and acute medication use were collected through preadmission and postadmission clinic notes. Safety and tolerability were evaluated. Results were evaluated using descriptive statistics and compared with paired t-tests.

RESULTS

Forty-five patients were identified for review. Patients with CM had a median of 7 previous preventive trials, and 85% had previously received alternative intravenous treatment for headache. Baseline headache pain significant decreased from 6.9/10 to 5.4/10 by 7-week postadmission follow up, (95% confidence interval = -0.7 to -2.4), P < 0.001. Use of medications for acute headache treatment decreased significantly from 2.1 days/week to 1.5 days/week, (95% confidence interval = -0.3 to -1), P < 0.001. Baseline headache frequency did not significantly change. At postadmission follow-up, 26 of 39 (67%) patients saw improvements in headache frequency, headache intensity, and/or acute pain medication usage. There were no serious adverse events.

CONCLUSIONS

Repetitive sodium valproate infusions were well tolerated and significantly reduced baseline headache intensity and acute medication usage in pediatric patients with refractory, chronic headache disorders.

Effects and side effects of migraine prophylaxis in children

BACKGROUND

Migraine is the primary cause of headache in children. Most patients can be treated with lifestyle changes and acute attack prophylaxis. Prophylaxis should be considered when symptoms cause frequent school absenteeism, poor quality of life, recurring emergency room visits, and frequent analgesic use. We aimed to compare the efficacy and side effects of drugs used in migraine prophylaxis, chosen according to the clinical and/or demographic characteristics of the patients.

METHODS

One hundred eighty-six patients aged 6-18 years were evaluated and who were diagnosed with migraine according to The International Classification of Headache Disorders, 3rd edition beta version (ICH-3β). Propranolol, topiramate, flunarizine, and cyproheptadine were given as prophylactic treatment. The Pediatric Migraine Disability Assessment Score (PedMIDAS) score, severity, duration, and frequency of the headache attacks were evaluated from the medical records and pre- and post-treatment values were compared.

RESULTS

The median age of the patients was 14 years (range, 6-18 years) and the mean duration of headache was 29.6 ± 21.02 months. The mean PedMIDAS score was 29.9 ± 21.2 before and 14.9 ± 12.5 after treatment. Most reduction in the frequency of attacks was observed in the topiramate group. All four drugs significantly reduced the PedMIDAS score. The most common side effect was palpitations.

CONCLUSIONS

Significant improvement was found in PedMIDAS scores in all drug groups. Topiramate was found to be the most effective drug in reducing the frequency of attacks. All four drugs in this study may be utilized for migraine prophylaxis in terms of effectiveness and safety.

Advances in topiramate as prophylactic treatment for migraine

It is well-known that topiramate as a kind of antiepileptic drug has been proved effective for migraine prevention in North America and Europe. However, topiramate is still viewed as an off-label medication for migraine treatment in China, partly because of the limited evidence in Chinese patients. We summarize the effects of topiramate on the frequency, severity, quality-of-life, and adverse event among migraine patients, including children and adolescent in this review, so as to provide reference for Chinese doctors.

Management of headaches in children and adolescents

Pediatric headache impacts up to 80% of children, many recurrently, by the time they are 15 years old. Preventing the progression of episodic to chronic headache results in less truancy, staying current with schoolwork and improves children's quality of life. Lifestyle choices can play an important role in headache treatment. Early effective treatment of episodic headache can prevent transformation into a chronic form. While details of a child's headache are critical for making a proper diagnosis; patient education is critical and effective rescue and preventive treatment strategies enable patients to focus on enjoying activities of daily living. Recognizing "red flags" that may suggest a serious underlying etiology is critical in the early stages of diagnosing and preparing to treat children with headaches. Finally directing patients to manage their headaches at home and when to proceed to an emergency department, urgent care or infusion unit can lower the economic burden of acute headache management.

The efficacy and safety of antiepileptics in the prophylaxis of pediatric migraine: the meta-analysis of randomized controlled trials

BACKGROUND

Migraine is the most common primary headache among children and adolescents. The aim of this meta-analysis was to evaluate the efficacy and safety of antiepileptic drugs in the prevention of pediatric migraine.

METHODS

PubMed, Cochrane Library, EMBASE and Chinese National Knowledge Infrastructure (CNKI) databases were searched for eligible published RCTs from January 1970 to June 2020. Migraine frequency and ≥50% response rate were measured as the efficacy outcomes. We used "Risk of Bias" tool for quality assessment and RevMan5.3 software for statistical analysis.

RESULTS

Four articles containing 7 RCTs with 794 participants compared the efficacy of AEDs with placebo. Four RCTs assessed topiramate vs. placebo and 3 RCTs evaluated divalproex sodium extended-release (DVPX ER) vs. placebo. The results demonstrated that children receiving antiepileptic drugs had a significant advantage in remitting the mean monthly migraine days compared to those who received placebo, with an MD of -0.48 (n=930, 95% CI: -0.84 to -0.12, Z=2.60, P=0.009). Topiramate significantly reduced monthly migraine days (MD =-0.70, n=489, 95% CI: -1.16 to -0.25, Z=3.01, P=0.003) but failed to improve the ≥50% response rate (MD =-1.50, n=489, 95% CI: 0.70 to 3.22, Z=1.05, P=0.30). DVPX ER did not significantly reduce monthly headache frequency (n=441, 95% CI: -0.70 to 0.47, Z=0.38, P=0.70) or improve the ≥50% response rate (n=441, 95% CI: 0.59 to 1.25, Z=0.82, P=0.41) compared with placebo. Topiramate and DVPX ER were related to higher rates of side effects and adverse reactions.

DISCUSSION

Topiramate can reduce monthly headache days in children and adolescents with migraine. However, it failed to improve the ≥50% response rate. DVPX ER showed no difference from placebo in the prophylactic treatment pediatric migraine. Side effects seemed to be more frequent in topiramate and DVPX ER treated children but generally well-tolerated.

Prevalence of Headache Days and Disability 3 Years After Participation in the Childhood and Adolescent Migraine Prevention Medication Trial

IMPORTANCE

Migraine is a common neurological disease that often begins in childhood and continues into adulthood; approximately 6 million children and adolescents in the United States cope with migraine, and many frequently experience significant disability and multiple headache days per week. Although pharmacological preventive treatments have been shown to offer some benefit to youth with migraine, additional research is needed to understand whether and how these benefits are sustained.

OBJECTIVE

To survey clinical status of youth with migraine who participated in the 24-week Childhood and Adolescent Migraine Prevention (CHAMP) trial over a 3-year follow-up period.

DESIGN, SETTING, AND PARTICIPANTS

This survey study used internet-based surveys collected from youth ages 8 to 17 years at 3, 6, 12, 18, 24, and 36 months after completion of the CHAMP trial, which randomized participants to amitriptyline, topiramate, or placebo. At the end of the trial, the study drug was stopped, and participants received clinical care of their choice thereafter. The CHAMP trial was conducted between May 2012 and November 2015, and survey follow-up was conducted June 2013 to June 2018. Participants in this survey study were representative of those randomized in the trial. Data were analyzed from March 2020 to April 2021.

EXPOSURES

Survey completion.

MAIN OUTCOMES AND MEASURES

Headache days, disability (assessed using the Pediatric Migraine Disability Scale [PedMIDAS]), and self-report of ongoing use of prescription preventive medication.

RESULTS

A total of 205 youth (mean [SD] age, 14.2 [2.3] years; 139 [68%] girls; mean [SD] history of migraine, 5.7 [3.1] years) participated in the survey. Retention of participants was 189 participants (92%) at month 6, 182 participants (88%) at month 12, 163 participants (80%) at month 18, 165 participants (80%) at month 24, and 155 participants (76%) at month 36. Over the course of the 3-year follow-up, participants consistently maintained meaningful reductions in headache days (mean [SD] headache days per 28 days: CHAMP baseline, 11.1 [6.0] days; CHAMP completion, 5.0 [5.7] days; 3-year follow-up, 6.1 [6.1] days) and disability (mean [SD] score: CHAMP baseline, 40.9 [26.4]; CHAMP completion, 17.9 [22.1]; 3-year follow-up, 12.3 [20.0]). At 3 years after completion of the CHAMP trial, headache days were approximately 1.5 per week (changed from about 3 per week at trial baseline) and disability had improved from the moderate range to the low mild range on the PedMIDAS. Longitudinal analyses showed that amitriptyline and topiramate did not explain intercept random effects for either mean rate of headache days per week (amitriptyline: estimate [SE], 0.07 [0.05]; P = .16; topiramate: estimate [SE], 0.04 [0.05]; P = .50) or headache disability PedMIDAS total score (amitriptyline: estimate [SE], 0.25 [0.38]; P = .52; topiramate: estimate [SE], -0.09 [0.39]; P = .82) changes over time. Of 153 participants who reported on prescription drug use at 3 years, only 1 participant (1%) reported using prevention medication, and most participants reported no medication use at most time points.

CONCLUSIONS AND RELEVANCE

These findings suggest that children and adolescents with longer than 5 years history of migraine who participated in the CHAMP trial may sustain positive clinical outcomes over time, even after discontinuing preventive pill-based treatment. This survey study could inform use and discontinuation timing of pharmacological preventive therapies for migraine in youth ages 8 to 17 years. Research is needed to examine mechanisms of treatment improvement and maintenance for preventive therapies, as well as placebo, in the pediatric population.

Management of Chronic Migraine in Children and Adolescents: A Brief Discussion on Preventive Therapies

Pediatric migraine is a debilitating disease that affects about 10% of school-aged children. Like other pain disorders, migraines can be accompanied with sleep, mood, and cognitive difficulties, leading to interruptions in daily tasks required at both school and home. This paper serves as a review of the most current pharmacological treatments available for managing migraine in the pediatric population. Because the management of migraine is complex, we discuss the importance of multidisciplinary care involving pharmacological and non-pharmacological measures, behavioral modifications, and a shared treatment plan between the clinician, patient, and parent/care giver. A diverse group of medications are used to prevent migraine attacks including antiepileptics, antidepressants, antihistamines, and antihypertensive agents, in addition to newer classes of medications; yet there remains a serious lack of controlled studies in the pediatric population. Further clinical research is necessary to have Food and Drug Administration (FDA)-approved medications readily available for migraine sufferers.

The association between melatonin and episodic migraine: A pilot network meta-analysis of randomized controlled trials to compare the prophylactic effects with exogenous melatonin supplementation and pharmacotherapy

Although exogenous melatonin supplementation has been suggested to be effective for episodic migraine prophylaxis, there is no conclusive evidence comparing the efficacy of exogenous melatonin supplementation to the other FDA-approved pharmacotherapy for episodic migraine prophylaxis. The aim of the current network meta-analysis (NMA) was to compare the efficacy of exogenous melatonin supplementation in patients with episodic migraine. The randomized placebo-controlled trials or randomized controlled trials (RCTs) incorporating a placebo in the study designs were included in our analyses. All of the NMA procedures were conducted under the frequentist model. The primary outcome was changes in frequency of migraine days and response rate after migraine prophylaxis with melatonin supplementation or pharmacological interventions. We included 25 RCTs in total with 4499 patients (mean age = 36.0 years, mean female proportion = 78.9%). The NMA demonstrated that migraine prophylaxis with oral melatonin 3 mg/d (immediate-release) at bedtime was associated with the greatest improvement in migraine frequency [mean difference = -1.71 days, 95% confidence interval (CI): -3.27 to -0.14 days compared to placebo] and the second highest response rate (odds ratio = 4.19, 95% CI = 1.46 to 12.00 compared to placebo). Furthermore, oral melatonin 3 mg (immediate-release) at bedtime was the most preferred pharmacological intervention among all of the investigated interventions when improvements in migraine frequency, response rate, dropout rate, and rates of any adverse events were taken into account. This pilot NMA suggests the potential prophylactic role of exogenous melatonin supplementation in patients with episodic migraine.

Efficacy, Safety, and Acceptability of Pharmacologic Treatments for Pediatric Migraine Prophylaxis: A Systematic Review and Network Meta-analysis

IMPORTANCE

Migraine is one of the most common neurologic disorders in children and adolescents. However, a quantitative comparison of multiple preventive pharmacologic treatments in the pediatric population is lacking.

OBJECTIVE

To examine whether prophylactic pharmacologic treatments are more effective than placebo and whether there are differences between drugs regarding efficacy, safety, and acceptability.

DATA SOURCES

Systematic review and network meta-analysis of studies in MEDLINE, Cochrane, Embase, and PsycINFO published through July 2, 2018.

STUDY SELECTION

Randomized clinical trials of prophylactic pharmacologic treatments in children and adolescents diagnosed as having episodic migraine were included. Abstract, title, and full-text screening were conducted independently by 4 reviewers.

DATA EXTRACTION AND SYNTHESIS

Data extraction was conducted according to Preferred Reporting Items for Systematic Reviews and Meta-Analysis network meta-analysis guidelines. Quality was assessed with the Cochrane Risk of Bias tool. Effect sizes, calculated as standardized mean differences for primary outcomes and risk ratios for discontinuation rates, were assessed in a random-effects model.

MAIN OUTCOMES AND MEASURES

Primary outcomes were efficacy (ie, migraine frequency, number of migraine days, number of headache days, headache frequency, or headache index), safety (ie, treatment discontinuation owing to adverse events), and acceptability (ie, treatment discontinuation for any reason).

RESULTS

Twenty-three studies (2217 patients) were eligible for inclusion. Prophylactic pharmacologic treatments included antiepileptics, antidepressants, calcium channel blockers, antihypertensive agents, and food supplements. In the short term (<5 months), propranolol (standard mean difference, 0.60; 95% CI, 0.03-1.17) and topiramate (standard mean difference, 0.59; 95% CI, 0.03-1.15) were significantly more effective than placebo. However, the 95% prediction intervals for these medications contained the null effect. No significant long-term effects for migraine prophylaxis relative to placebo were found for any intervention.

CONCLUSIONS AND RELEVANCE

Prophylactic pharmacologic treatments have little evidence supporting efficacy in pediatric migraine. Future research could (1) identify factors associated with individual responses to pharmacologic prophylaxis, (2) analyze fluctuations of migraine attack frequency over time and determine the most clinically relevant length of probable prophylactic treatment, and (3) identify nonpharmacologic targets for migraine prophylaxis.

The Efficacy and Safety of Topiramate in the Prevention of Pediatric Migraine: An Update Meta-Analysis

Background: Migraine is the most common acute primary headache in children and adolescents. In 2014, topiramate became the first preventive drug for migraine, approved by the Food and Drug Administration (FDA) for adolescents. This meta-analysis was aimed to evaluate the efficacy and safety of topiramate in the prevention of pediatric migraine. Methods: We searched the PubMed, EMBASE, Cochrane Library, and Chinese National Knowledge Infrastructure (CNKI) databases up to June 2019 for eligible randomized controlled trials (RCTs). The primary outcomes were mean migraine days per month, ≥50% reduction rate, and Pediatric Migraine Disability Assessment Scale (PedMIDAS) scores. RevMan5.3 software was performed for statistical analysis. Results: Overall, 5 RCTs recruiting 531 patients (6-17 years of age) were included in the meta-analysis. The target dose of topiramate was 2 mg/kg (the maintenance phase was 12 weeks), 2-3 mg/kg, 50 mg/day, and 100 mg/day (maintaining for 16 weeks), respectively, in the included studies. Our results demonstrate that participants receiving topiramate had a significant advantage in remitting the monthly migraine days than those receiving placebo, with a mean difference (MD) of -0.78 (n = 531; 95% CI, -1.23 to -0.32; Z = 3.37; P = 0.0008). Topiramate could also reduce the mean PedMIDAS scores (n = 238; 95% CI, -16.53 to -0.49; Z = 2.43; P = 0.04). However, there was no significant difference in the percentage of patients experiencing a ≥50% reduction in monthly headache days between topiramate and placebo groups (n = 531; 95% CI, 0.94-1.77; Z = 1.58; P = 0.11). Topiramate was associated with higher rates of side effects such as weight decrease (n = 395; 95% CI, 2.73-22.98; Z = 3.81; P < 0.01) and paresthesia (n = 531; 95% CI, 3.05-13.18; Z = 4.94; P < 0.01). Conclusions: Topiramate can significantly decrease monthly headache days and migraine-related burden in migraine patients <18 years old. However, it failed to increase 50% response rate. Adverse events seem to be more frequent in topiramate-treated children.

Pediatric Migraine: An Update

This article outlines key features of diagnosis and treatment of migraine in children and adolescents. It emphasizes techniques that can be used by clinicians to optimize history taking in this population, as well as recognition of episodic conditions that may be associated with migraine and present in childhood. Acute treatment strategies include use of over-the-counter analgesics and triptan medications that have been approved by the US Food and Drug Administration for use in children and adolescents. Preventive treatment approach includes lifestyle modifications, behavioral strategies, and consideration of preventive medications with the lowest side effect profiles.

Practice guideline update summary: Pharmacologic treatment for pediatric migraine prevention: Report of the Guideline Development, Dissemination, and Implementation Subcommittee of the American Academy of Neurology and the American Headache Society

OBJECTIVE

To provide updated evidence-based recommendations for migraine prevention using pharmacologic treatment with or without cognitive behavioral therapy in the pediatric population.

METHODS

The authors systematically reviewed literature from January 2003 to August 2017 and developed practice recommendations using the American Academy of Neurology 2011 process, as amended.

RESULTS

Fifteen Class I-III studies on migraine prevention in children and adolescents met inclusion criteria. There is insufficient evidence to determine if children and adolescents receiving divalproex, onabotulinumtoxinA, amitriptyline, nimodipine, or flunarizine are more or less likely than those receiving placebo to have a reduction in headache frequency. Children with migraine receiving propranolol are possibly more likely than those receiving placebo to have an at least 50% reduction in headache frequency. Children and adolescents receiving topiramate and cinnarizine are probably more likely than those receiving placebo to have a decrease in headache frequency. Children with migraine receiving amitriptyline plus cognitive behavioral therapy are more likely than those receiving amitriptyline plus headache education to have a reduction in headache frequency.

RECOMMENDATIONS

The majority of randomized controlled trials studying the efficacy of preventive medications for pediatric migraine fail to demonstrate superiority to placebo. Recommendations for the prevention of migraine in children include counseling on lifestyle and behavioral factors that influence headache frequency and assessment and management of comorbid disorders associated with headache persistence. Clinicians should engage in shared decision-making with patients and caregivers regarding the use of preventive treatments for migraine, including discussion of the limitations in the evidence to support pharmacologic treatments.

Treatment of migraine attacks and prevention of migraine: Guidelines by the German Migraine and Headache Society and the German Society of Neurology

In collaboration with some of the leading headache centres in Germany, Switzerland and Austria, we have established new guidelines for the treatment of migraine attacks and the prevention of migraine. A thorough literature research of the last 10 years has been the basis of the current recommendations. At the beginning, we present therapeutic novelties, followed by a summary of all recommendations. After an introduction, we cover topics like drug therapy and practical experience, non-effective medication, migraine prevention, interventional methods, non-medicational and psychological methods for prevention and therapies without proof of efficacy.

Plasma Calcitonin Gene-Related Peptide: A Potential Biomarker for Diagnosis and Therapeutic Responses in Pediatric Migraine

Background: Plasma calcitonin gene-related peptide (CGRP) plays a key role in the migraine pathophysiology. This study aimed to investigate its role in predicting diagnosis and outcome of pharmacotherapy in pediatric migraine.

Methods: We prospectively recruited 120 subjects, who never took migraine-preventive agents in a pediatric clinic, including 68 patients with migraine, 30 with non-migraine headache (NM), and 22 non-headache (NH) age-matched controls. Short-term therapeutic response was measured for at least 2 weeks after the start of therapy. Responders were defined with >50% headache reduction. Plasma CGRP concentrations were measured by ELISA.

Results: In the migraine group, more patients required acute therapy, as compared to the NM group (62/68, 91% vs. 5/30, 15%, p = 0.001). The mean plasma CGRP level in migraineurs either during (291 ± 60 pg/ml) or between (240 ± 48) attacks was higher than in NM patients (51 ± 5 pg/ml, p = 0.006 and 0.018, respectively) and NH controls (53 ± 6 pg/ml, p = 0.016 and 0.045, respectively). Forty-seven patients (69%) needed preventive treatments and had higher plasma CGRP levels (364 ± 62 pg/ml, n = 47) than those not (183 ± 54 pg/ml, n = 21) (p = 0.031). Topiramate responders had higher plasma CGRP levels than non-responders (437 ± 131 pg/ml, n = 14 vs. 67 ± 19 pg/ml, n = 6, p = 0.021). Survival curves of plasma CGRP levels also showed those with higher CGRP levels responded better to topiramate. Differences were not found in the other preventives.

Conclusion: The plasma CGRP level can differentiate migraine from non-migraine headache. It may also serve as a reference for the therapeutic strategy since it is higher in patients requiring migraine prevention and responsive to short-term topiramate treatment. These results are clinically significant, especially for the young children who cannot clearly describe their headache symptoms and may provide new insights into the clinical practice for the diagnosis and treatment of pediatric migraine.

Diagnosing and managing migraine in children and young people

This article gives an overview of migraine in children. It outlines the epidemiology of the condition and describes presentation with headache and other symptoms and linked conditions. It aims to raise awareness of the diagnosis of migraine and its impact on children and young people, their families and school life. The author also describes methods of diagnosis and management, and the importance of recognising and of avoiding medication overuse.

Non-pharmacological Approaches for Headaches in Young Age: An Updated Review

Headache disorders are common in children and adolescents. Most of the studies on non-pharmacological treatments have however been carried out on adults. In this review we provide information on recent studies examining non-pharmacological approaches for managing headache in children and adolescents. Our search of SCOPUS for primary studies conducted between January 2010 and July 2018 uncovered 11 controlled studies, mostly addressing behavioral approaches, in which a total of 613 patients with a diagnosis of primary headache, and average age 10.2–15.7 years (30–89% females) were recruited. Non-pharmacological treatments were shown to produce sizeable effects on the classical primary endpoint, i.e., headache frequency, with reductions from baseline ranging between 34 and 78%. Among commonly reported secondary endpoints, particularly disability, quality of life, depression and anxiety, marked improvements were noted as well. Taken as a whole, our findings suggest that non-pharmacological treatments constitute a valid option for the prevention of primary headaches in young age. Future research with higher-quality studies is needed. Particular attention needs to be given to studies that randomize patients to condition, blind researchers in charge of evaluating treatment outcomes, routinely include headache frequency as the primary endpoint, include adequate-length follow-up, address changes in biomarkers of disease and other possible mediators of outcome, and that employ predictive models to enhance the level of evidence for these approaches.

Cognitive Behavioral Therapy for Pediatric Headache and Migraine: Why to Prescribe and What New Research Is Critical for Advancing Integrated Biobehavioral Care

PURPOSE OF REVIEW

To highlight current evidence supporting the prescription of cognitive behavioral therapy (CBT) as part of first-line preventive treatment for children and adolescents with headache and discuss a research strategy aimed at: (1) understanding how and why CBT works, and (2) developing effective and efficient approaches for integrating CBT into headache specialty, neurology, and primary care settings.

RECENT FINDINGS

Although preventive medications for pediatric headache and migraine are commonly prescribed, recent meta-analyses and an NIH-funded, multi-center clinical trial suggests that the effect of pill-taking therapies may be mostly due to a placebo effect. These findings have led to greater consideration of prescription of non-pharmacological therapies as first-line interventions (either alone or in combination with pill-based therapy). A literature that extends back to the 1980s and includes recent clinical trials and meta-analyses demonstrates that CBT decreases headache frequency and related disability in youth with headache and migraine and has a favorable benefit to risk profile with almost no negative side effects.

SUMMARY

CBT has been repeatedly demonstrated as effective in treating pediatric headache and migraine. As such, it should be considered as part of first-line preventive treatment for pediatric headache (either alone or in combination with a pill-based therapy). We need to better understand how this therapy works and what makes it distinct (if anything) from the placebo effect. What we need to achieve is empirical support for efficient access to this evidence-based treatment and clarity on how to match the intensity of non-pharmacological intervention to the needs of our patients at the time they present for care.

Topiramate for Seizures in Preterm Infants and the Development of Necrotizing Enterocolitis

Neonatal seizures represent a significant health burden on the term and preterm neonatal population and are linked to poor long-term neurodevelopmental outcomes. Currently, there are no US Food and Drug Administration-approved antiepileptic drugs for neonates, and authors of the medical literature have yet to reach a consensus on the most adequate approach to neonatal seizures. Topiramate is readily used in the adult and older pediatric population for the management of migraines and partial-onset seizures. Topiramate continues to gain favor among pediatric neurologists who often recommend this medication as a third-line treatment of neonatal seizures. We report our recent experience with 4 preterm neonates, born between 2015 and 2017, who developed radiographic signs of necrotizing enterocolitis after receiving topiramate for seizures. Each was given oral topiramate for the treatment of electrographic and clinical seizures and developed the subsequent diagnosis of necrotizing enterocolitis, with abdominal distention, hemoccult-positive stools, and radiographic signs of intestinal distention and pneumatosis. More research regarding the risk factors of topiramate use in premature infants is needed.

[Comorbidity of migraine and epilepsy in childhood]

Migraine and epilepsy represent prevalent chronic neurological disorders of childhood. Migraine and epilepsy comorbidity relies on the common pathophysiologic and genetic mechanisms of the paroxysmal disorders the similarity of their precipitating factors, clinical manifestations and therapeutic approaches. The problems of differential diagnosis of migraine and epilepsy are related to peculiarities of migraine manifestations in children. Some forms of epilepsy could be accompanied by cephalgic seizures. The diagnostic criteria of headaches in epileptic patients are presented. A number of genetic diseases accompanying by migraine and epilepsy could be a model for delineation of shared pathogenetic mechanisms of these paroxysmal disorders in which genetically determined channelopathies may play an important role. The efficacy of antiepileptic drugs has been proven as the prophylactic treatment of migraine in pediatric patients. The advantages of levetiracetam as the prophylactic treatment for migraine and epilepsy comorbidity in children are discussed.

Management of Pediatric Migraine: Current Therapies

Migraine is one of the most common neurologic conditions in pediatrics. It can be a significant stressor, causing absences from school and interruption of parents' work and family schedules. The mainstay of treatment remains educating patients about healthy lifestyle practices and the influences of sleep, stressors, and hydration on triggering migraine attacks. Psychological therapies such as biofeedback or cognitive-behavioral therapy may be beneficial in some patients, especially those with prominent psychological comorbidities. New advances in the pathophysiology of migraine and additional pediatric approval of abortive therapy with triptans have led to significant advances in the management of migraine in children. Some challenges to preventive therapy were recently noted with the negative results obtained in the Childhood and Adolescent Migraine Prevention Study, which compared prescription drugs to placebo. Inherent differences between adult and pediatric headaches, with shorter duration of pediatric migraine and prominent placebo effect, present recurring challenges for clinicians. [Pediatr Ann. 2018;47(2):e55-e60.].

Similarities and Differences Between Migraine in Children and Adults: Presentation, Disability, and Response to Treatment

PURPOSE OF REVIEW

This review presents findings from investigations of migraine in children and adults. Similarities and differences in the presentation, related consequences, and treatments between children and adults are reviewed.

RECENT FINDINGS

Significant similarities exist in the presentation, disability, and treatments for migraine between children and adults. Despite such similarities, many adult migraine treatments adapted for use in children are not rigorously tested prior to becoming a part of routine care in youth. Existing research suggests that not all approaches are equally effective across age groups. Specifically, psychological treatments are shown to be somewhat less effective in adults than in children. Pharmacological interventions found to be statistically significant relative to placebo in adults may not be as effective in children and have the potential to present more risk than benefit when used in youth. The placebo effect in both children and adults is robust and is need of further study. Better understanding of treatment mechanisms for all interventions across the age spectrum is needed. Although migraine treatments determined to be effective for adults are frequently adapted for use in children with little evaluation prior to implementation, existing research suggests that this approach may not be the best practice. Adaptation of adult pharmacological treatment for use in youth may present a particular risk in comparison to benefits gained. Because of the known efficacy of psychological treatments, such as cognitive behavioral therapy, more universal use of these interventions should be considered, either as first-line treatment or in combination with pill-based therapies.

Effects of low-dose topiramate on language function in children with migraine

Purpose

This study aimed to verify the safety of low-dose topiramate on language development in pediatric patients with migraine.

Methods

Thirty newly diagnosed pediatric patients with migraine who needed topiramate were enrolled and assessed twice with standard language tests, including the Test of Language Problem Solving Abilities (TOPs), Receptive and Expressive Vocabulary Test, Urimal Test of Articulation and Phonology, and computerized speech laboratory analysis. Data were collected before treatment, and topiramate as monotherapy was sustained for at least 3 months. The mean follow-up period was 4.3±2.7 months. The mean topiramate dosage was 0.9 mg/kg/day.

Results

The patient's mean age was 144.1±42.3 months (male-to-female ratio, 9:21). The values of all the language parameters of the TOPs were not changed significantly after the topiramate treatment as follows: Determine cause, from 15.0±4.4 to 15.4±4.8 (P>0.05); making inference, from 17.6±5.6 to 17.5±6.6 (P>0.05); predicting, from 11.5±4.5 to 12.3±4.0 (P>0.05); and total TOPs score, from 44.1± 13.4 to 45.3±13.6 (P>0.05). The total mean length of utterance in words during the test decreased from 44.1±13.4 to 45.3±13.6 (P<0.05). The Receptive and Expressive Vocabulary Test results decreased from 97.7±22.1 to 96.3±19.9 months, and from 81.8±23.4 to 82.3±25.4 months, respectively (P>0.05). In the articulation and phonology validation in both groups, speech pitch and energy were not significant, and all the vowel test results showed no other significant values.

Conclusion

No significant difference was found in the language-speaking ability between the patients; however, the number of vocabularies used decreased. Therefore, topiramate should be used cautiously for children with migraine.

Is topiramate effective for migraine prevention in patients less than 18 years of age? A meta-analysis of randomized controlled trials

Background

Mainly based on evidence of success in adults, various medications are commonly used to prevent pediatric migraines. Topiramate has been approved for migraine prevention in children as young as 12 years of age. In this meta-analysis, we aimed to assess the currently published data pertaining to the efficacy of topiramate for migraine prevention in patients less than 18 years of age.

Methods

We searched PubMed/Medline, Embase and the Cochrane Library (from inception to April 2017) for randomized controlled trials (RCTs) published in English. Two independent investigators performed data extraction and quality evaluation using the Cochrane Collaboration’s tool. The data extracted were analyzed by Review Manager 5.3 software.

Results

A total of four RCTs matching the inclusion criteria were included, with an aggregate of 465 patients. Of these patients, 329 were included in the topiramate group, and 136 were included in the placebo group. This meta-analysis revealed that compared with placebo, topiramate failed to decrease the number of patients experiencing a ≥ 50% relative reduction in headache frequency (n = 465, RR = 1.26, 95% CI = [0.94,1.67], Z = 1.55, P = 0.12) or the number of headache days (n = 465, MD = −0.77, 95% CI = [−2.31,0.76], Z = 0.99, P = 0.32) but did reduce PedMIDAS scores (n = 205, MD = −9.02, 95% CI = [−17.34, −0.70], Z = 2.13, P = 0.03). Higher rates of side effects and adverse events in the topiramate group than in the placebo group were observed in the included trials.

Conclusions

Topiramate may not achieve a more effective clinical trial endpoint than placebo in the prevention of migraines in patients less than 18 years of age, and topiramate may lead to more side effects or adverse events in the included patients.

Pediatric Headache: An Overview

Headache represents the most common neurologic disorder in the general population including children and is increasingly being recognized as a major source of morbidity in youth related to missed school days and activities. In this article, we take a holistic approach to the child presenting with headache with a focus on the detailed headache history, physical and neurologic examinations, and diagnostic evaluation of these patients. Clinical presentations and classification schema of multiple primary and secondary headache types in children are discussed using the International Headache Criteria (IHCD-3) as a guide, and a summary provided of the various treatment modalities employed for pediatric headache including lifestyle modifications, behavioral techniques, and abortive and preventive medications.

Factors Associated with Favorable Outcome of Topiramate Migraine Prophylaxis in Pediatric Patients

BACKGROUND AND PURPOSE

There are few studies that have investigated predictive factors related to migraine prophylaxis of which produced inconsistent results. The aim of this study was to identify factors that can predict the treatment response to topiramate prophylaxis in pediatric patients with migraine.

METHODS

One hundred and thirteen patients who were older than 7 years and received topiramate for at least 3 months were recruited from the Seoul National University Bundang Hospital outpatient clinic from 2005 to 2014. A positive response was defined as a reduction of more than 50% in the number of migraine episodes after topiramate treatment. Proposed predictive factors such as migraine characteristics including severity and frequency were assessed, as were other data on sex, disease duration, associated symptoms, family history, and impairment of daily activities.

RESULTS

Seventy patients (61.9%) responded to prophylactic treatment with topiramate. Patients who experienced significant impairment in daily activities showed significant benefit from the treatment (p=0.004). Sex, the severity, frequency, and duration of migraine episodes, disease duration, treatment duration, age at onset, and associated symptoms were not significantly related to a response to topiramate treatment.

CONCLUSIONS

Migraine characteristics and associated symptoms were not significantly related to a response to topiramate treatment. However, patients with significant impairment in daily activities showed significant benefit from the treatment, and so prophylactic topiramate treatment should be strongly encouraged in this patient group.

Newly Approved Agents for the Treatment and Prevention of Pediatric Migraine

Treatment of pediatric migraine remains an unmet medical need. There continues to be a paucity of pediatric randomized controlled trials for the treatment of migraine, both in the acute and preventive settings. Pediatric studies are often complicated by high placebo-response rates and much of our current practice is based on adult trials. This lack of significant pediatric studies results in a wide variation in migraine management both amongst clinicians and between institutions, and evidence-based treatments are not always administered. In this article, we aim to briefly review newly approved abortive and preventive agents for migraine in the pediatric age group. Over-the-counter anti-inflammatory medications, including ibuprofen, naproxen sodium, aspirin, and acetaminophen are reasonable first-line options for abortive therapy. In addition, studies have shown triptans, or migraine-specific agents, to be safe and effective in children and adolescents and several formulations have been approved for the pediatric population, including rizatriptan, almotriptan, zolmitriptan nasal spray, and naproxen sodium/sumatriptan in combination.

Medication Repurposing in Pediatric Patients: Teaching Old Drugs New Tricks

OBJECTIVES

Gaps in pediatric therapeutics often result in off-label use and specifically, novel uses for existing medications, termed "drug repurposing." Drug Information (DI) queries to a Pediatric Medication Resource Center of a large metropolitan pediatric hospital in New York and inherent difficulties in retrieving evidence-based information prompted a review of current medication repurposing for pediatric patients. The objective included characterization of innovative off-label use of medications Food and Drug Administration (FDA)-approved for 1 or more indications to treat a totally different disorder or indication in pediatric patients.

METHODS

A systematic literature review was conducted to retrieve publications describing repurposed medications in pediatric patients. Excluded was FDA-approved indications used off-label in pediatric patients (e.g., different dose), preclinical data, adult use only, and experimental use. Evidence quality was classified using a modified American Academy of Neurology Level of Evidence. Results were analyzed using χ(2) at p < 0.05.

RESULTS

Over 2000 references were retrieved and reviewed. A total of 101 medications repurposed for novel off-label uses for pediatric patients were identified: 38 for neonates, 74 for children, and 52 for adolescents. Neonates and infants were least likely to receive a medication for a repurposed use. Strong or intermediate evidence existed in 80.2% of cases. The evidence was weak in 19.8%. No significant relationship was observed between the pediatric age group and strength of the literature. Most repurposed uses pertained to generic or widely used medications. Less than 5% of medications were first marketed after 2011.

CONCLUSIONS

While not exhaustive, the present study represents the most comprehensive listing of novel uses exclusive to pediatric patients. Further research is needed to identify the frequency of repurposed uses. The valuable DI role of pharmacists in assessing repurposed uses is of expanding and increasing importance to ensure such uses are evidence-based.

The optimal management of headaches in children and adolescents

The recognition of the diagnosis of migraine in children is increasing. Early and aggressive treatment of migraine in this population with the use of over-the-counter medications has proven effective. The off-label use of many migraine-specific medications is often accepted in the absence of sufficient evidenced-based trials. Mild to severe cases of migraine should be treated with nonsteroidal anti-inflammatory drugs, with triptans used in moderate to severe headaches unresponsive to over-the-counter therapy. Rescue medication including dihydroergotamine [DHE] should be used for status migrainosus, preferably in the hospital setting. Antiemetics that have antidopaminergic properties can be helpful in patients with associated symptoms of nausea and vomiting through their action on central migraine generation. Furthermore, patients and families should be educated on nonpharmacologic management such as lifestyle modification and avoidance of triggers that can prevent episodic migraine.

Prophylaxis of migraine in children and adolescents

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.

Migraine management in children

Migraine management in children relies on understanding the difference between adult and childhood migraine, being able to identify childhood migraine variants and knowledge of both the pediatric and adult literature regarding treatment.

Treatment of pediatric migraine

OPINION STATEMENT

The diagnosis of migraine in the pediatric population is increasing as providers are becoming more familiar with recognizing the condition. Over-the-counter and migraine-specific treatment, once considered off-label, have proven to be effective, especially if given at the early onset of head pain. Mild to severe cases of migraine should be treated with nonsteroidal anti-inflammatory drugs (NSAIDs), with triptans used alone or in combination in moderate to severe headaches unresponsive to over-the-counter therapy. Rescue medication including dihydroergotamine (DHE), a potent vasoconstrictor should be used for intractable migraines and is preferred in the hospital setting. Anti-emetics that have anti-dopaminergic properties can be helpful in patients with associated symptoms of nausea and vomiting along with headache, especially when used in combination therapy. Preventative treatment should be initiated early in patients with frequent headaches to improve headache outcomes and quality of life. Patients and families should be educated on non-pharmacologic management, such as lifestyle modification and avoidance of triggers, that can prevent progression and worsening of migraine.

Preventive drugs in childhood and adolescent migraine

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.

Drug utilization in pediatric neurology outpatient department: A prospective study at a tertiary care teaching hospital

Background:

Neurological disorders are a significant cause of morbidity, mortality and adversely affect quality of life among pediatric patients. In India, more than 30% population is under 20 years of age, many of whom present late during the course of illness. Several drugs prescribed to pediatric population suffering from neurological disorders may be off label or unlicensed.

Aims and Objectives:

To study drug use pattern, identify off-label/unlicensed drug use and to check potential for drug-drug interactions in patients attending outpatient department of pediatric neurology at a tertiary care teaching hospital.

Methodology:

Prescriptions of patients attending pediatric neurology outpatient department were collected prospectively for 8 weeks. They were analyzed for prescribing pattern, WHO core prescribing indicators, off-label/unlicensed drug use and potential for drug-drug interactions.

Result:

A total of 140 prescriptions were collected, male female ratio being 2:1. Epilepsy was the most common diagnosis (73.57%) followed by breath holding spells, migraine and developmental disorders. Partial seizure was the most common type of epilepsy (52.42%). Average number of drugs prescribed per patient was 1.56. Most commonly prescribed drug was sodium valproate (25.11%) followed by phenytoin (11.41%). About 16% of the prescriptions contained newer antiepileptic drugs. More than 60% of the drugs were prescribed from WHO essential drug list. In 8.57% of cases drugs were prescribed in off-label/unlicensed manner. Twenty-six percent prescriptions showed potential for drug interactions.

Conclusion:

Epilepsy is the most common neurological disease among children and adolescents. Sodium valproate is the most commonly prescribed drug. A few prescriptions contained off-label/unlicensed drugs.

Topiramate and cognitive impairment: evidence and clinical implications

Topiramate is an antiepileptic drug (AED) with multiple mechanisms of action that has been shown to be effective in a number of neuropsychiatric disorders. However, cognitive dysfunction is frequently observed in such patients, often representing a relevant challenge in their management. Moreover, there is a long-held recognition that AEDs may profoundly affect cognitive functions. This paper reviews available data on cognitive adverse events in patients with neurological disorders treated with topiramate, discussing the role of different contributing factors such as the pharmacological properties of the drug, the specific features of the brain disorder, and other variables pertinent to the discussion. All studies agree that up to 10% of patients may complain of treatment-emergent adverse events on cognition. Such problems occur early during treatment (i.e. within 6 weeks) and emerge in a dose-dependent fashion, suggesting that such prevalence may be significantly reduced using the drug in monotherapy and adopting individualized doses and titration schedules. The magnitude of the problem is generally mild to moderate and the subjective perception of the patient needs to be taken into account. In fact, apart from language problems, data are not conclusive. Comparisons with new AEDs are limited to levetiracetam and lamotrigine, in both cases generally disfavoring topiramate, while data regarding first-generation AEDs show clear differences only for verbal fluency.