Topiramate for Migraine Prevention in Adolescents: A Pooled Analysis of Efficacy and Safety

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.

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.

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.

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.

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.

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.

Episodic migraines in children: limited evidence on preventive pharmacological treatments

The authors conducted a systematic literature review of preventive pharmacological treatments for episodic childhood migraines searching several databases through May 20, 2012. Episodic migraine prevention was examined in 24 publications of randomized controlled trials that enrolled 1578 children in 16 nonrandomized studies. Single randomized controlled trials provided low-strength evidence that propranolol would result in complete cessation of migraine attacks in 713 per 1000 children treated (95% confidence interval, 452-974); trazodone and nimodipine decreased migraine days, while topiramate, divalproex, and clonidine were no more effective than placebo in preventing migraines. Migraine prevention with multidisciplinary drug management was not sustained at 6 months. Divalproex resulted in treatment discontinuation due to adverse effects, and topiramate increased the risk of paresthesia, upper respiratory tract infection, and weight loss. Long-term preventive benefits and improvement in disability and quality of life are unknown. No studies examined quality of life or provided evidence for individualized treatment decisions.

Effective dose of topiramate in pediatric migraine prophylaxis

Objective:

Migraine is a common neurological disorder in childhood and adolescence. Topiramate is a new anticonvulsant drug, recently being used in migraine prophylaxis in adults, although it is not approved by the Food and Drug Administration for prevention of pediatric migraine. The present study was planned and performed to evaluate the efficacy of low-dose topiramate in pediatric migraine prophylaxis.

Materials and Methods:

A prospective study, including 60 patients with migraine headaches was performed for a period of two months. The patients were randomly divided into two treatment groups – treated by topiramate < 2 mg/kg/day and > 2 mg/kg/day. All the patients were evaluated at 0, 4, and 8 weeks of the study for the clinical response.

Results:

The patients receiving topiramate < 2 mg/kg/day (mean dose of 1.2 ± 0.7 mg/kg/day) showed a reduction in the mean (±SD) of migraine frequency from 6.2 (±2.4) to 3.0 (±1.8) episodes per month, headache intensity from 7.2 (±1.95) to 3.7 (±1.8) based on the Visual Analog Scale, and headache duration from 5.4 (±2.1) to 2.2 (±1.3) h. In the patients treated with topiramate > 2 mg/kg/day (mean dose of 2.4 ± 0.5 mg/kg/day), the mean (±SD) of monthly headache frequency reduced from 6.9 (±2.1) to 3.24 (±1.2) per month, intensity from 7.11 (±1.4) to 3.14 (±2.41), and headache duration from 5.2 (±2.4) to 1.8 (±1.2) h, at the end of follow-up (P > 0.05). The most common side effects of topiramate were paresthesias (five patients), anorexia (four patients), drowsiness (four patients).

Conclusion:

The results of this study demonstrated that low-dose of topiramate (<2 mg/kg/day) is effective, well-tolerated, safe, and suggested as an alternative prophylactic treatment for pediatric migraine.

Meta-analysis of efficacy of topiramate in migraine prophylaxis

OBJECTIVE:

To evaluate the treatment effects and safety of topiramate in migraine prophylaxis.

DATA RETRIEVAL:

We searched the Medline database, EMbase, Cochrane Library and China National Knowledge Infrastructure database for articles published between January 1995 and May 2011, using the key words “migraine”, “topiramate”, and “prophylaxis”.

SELECTION CRITERIA:

We selected randomized controlled trials of migraine patients, in which the experimental group was orally administered topiramate, and the control group was given placebo. Odds ratios (ORs) and mean differences (MDs) were calculated using a fixed effects model/random effects model. Quality evaluation and data extraction were performed independently by two researchers utilizing RevMan 5.0 software.

MAIN OUTCOME MEASURES:

Efficacy was recorded as the responder rate (response defined as at least a 50% reduction in average monthly migraine frequency) and change in mean monthly number of migraine days. Adverse events were recorded as the number of subjects exhibiting at least one adverse event.

RESULTS:

Eight randomized controlled trials were found to be appropriate, and had available data. The meta-analysis results revealed that topiramate (100 or 200 mg/d) was more effective than placebo in responder rate (OR = 2.97, 95% confidence interval (CI): 2.17–4.08, P < 0.01; OR = 2.35, 95%CI: 1.77–3.12, P < 0.01). Topiramate (100 mg/d) was more effective than placebo in terms of the change in mean monthly migraine days (MD: –1.14, 95%CI: –1.69 to –0.59, P < 0.01). The total incidence rate of adverse events for topiramate was higher than in the placebo group (P < 0.01), but most adverse events were mild to moderate.

CONCLUSION:

Overall, topiramate obtained good outcomes and safety in migraine prophylaxis.

Biofeedback therapy for pediatric headache: factors associated with response

OBJECTIVES

The goal of this study was to measure the effect of biofeedback therapy on pediatric headache and to identify factors associated with response to biofeedback therapy.

BACKGROUND

In the United States, 17% of children have frequent or severe headaches. Biofeedback therapy (BFT) appears to be an effective treatment for headaches in adults and is often recommended for children with headaches, but there are few data in the pediatric population. It is also not clear which patients are most likely to benefit from biofeedback therapy.

METHODS

We examined the records of patients, aged 8 to 18 years old, who were referred to a pediatric BFT clinic for management of headache between 2004 and 2008. We extracted data regarding patient and headache characteristics, medication use, family history, and measures of depression, anxiety, and somatization. Chronic headache was defined as ≥4 headache days/week. Positive response to biofeedback was defined as a 50% reduction in number of headache days/week or hours/week, or ≥3-point decrease in severity (0-10 scale) between first and last visits. We analyzed the responder rate for those with episodic and chronic headaches and performed multivariable analysis to determine what factors were associated with headache response to biofeedback therapy.

RESULTS

We analyzed records from 132 children who attended ≥2 biofeedback sessions. Median headache frequency dropped from 3.5 to 2 headache days/week between the first and last visits. The response rate was 58% overall; 48% for chronic headaches and 73% episodic headaches. In multivariate analysis, ability to raise hand temperature by >3°F at the last visit and use of selective serotonin reuptake inhibitors (SSRIs) were associated with a positive response, and preventive medication use was associated with nonresponse. Anxiety, depression, and somatization were not significantly associated with response to biofeedback therapy.

CONCLUSIONS

Biofeedback therapy appears to be an effective treatment for children and adolescents with both episodic and chronic headaches. Further study is warranted to compare biofeedback with other treatments for chronic pediatric headache. Use of SSRIs appears to be associated with a positive response to biofeedback therapy, but the reasons for this relationship are unclear and merit further study.

Patient outcome in migraine prophylaxis: the role of psychopharmacological agents

INTRODUCTION

Migraine is a serious illness that needs correct treatment for acute attacks and, in addition, a treatment prophylaxis, since patients with migraine suffer during acute attacks and also between attacks.

METHODS

A systematic review of the most relevant clinical trials of migraine headache and its epidemiology, pathophysiology, comorbidity, and prophylactic treatment (medical and nonmedical) was carried out using "Medline" and "PsychINFO" from 1973 to 2009. Approximately 110 trials met our inclusion criteria and were included in the current review.

RESULTS

The most effective pharmacological treatment for migraine prophylaxis is propranolol and anticonvulsants such as topiramate, valproic acid, and amitriptyline. Nonmedical treatments such as acupuncture, biofeedback, and melatonin have also been proposed. Peripheral neurostimulation has been suggested for the treatment of chronic daily headache that does not respond to prophylaxis and for the treatment of drug-resistant primary headache. The majority of the pharmacological agents available today have limited efficacy and may cause adverse effects incompatible with long-term use.

LIMITATIONS

The review was limited by the highly variable and often insufficient reporting of the complex outcome data and by the fact that migraine prophylaxis trials typically use headache diaries to monitor the course of the disease. The results of the different studies were also presented in different ways, making comparison of the results difficult.

DISCUSSION

An adequate prophylaxis is crucial in reducing disability and preventing the evolution of the problem into a chronic progressive illness. The implications of the present findings were discussed.

New drugs in migraine treatment and prophylaxis: telcagepant and topiramate

Although the triptan drugs provide effective relief from migraine for many patients, a substantial number of affected individuals are unresponsive to these compounds, and such therapy can also lead to a range of adverse effects. Telcagepant represents a new class of antimigraine drug-the calcitonin gene-related peptide receptor blockers. This compound exerts its effects by blocking receptors for the calcitonin-gene-related peptide at several sites in the trigeminal and central nervous systems, resulting in pain relief. Telcagepant does not cause vasoconstriction, a major limitation in the use of triptans. Comparisons with triptans in clinical trials for acute treatment of migraine attacks revealed clinical effects similar to those of triptans but better than those of placebo. Telcagepant might provide hope for those who have a poor response to, or are unable to use, older drugs. In patients who need prophylaxis because of frequent attacks of migraine, topiramate is a first-line drug for migraine prevention in many countries; it is generally safe and reasonably well tolerated. Data suggest that topiramate could aid reversion of chronic migraine to episodic migraine.

Migraine treatment in developmental age: guidelines update

There is a serious lack of controlled studies on the pharmacological treatment of primary migraine in the developmental age; there is, consequently, an urgent need for new, evidence-based approaches to this long-neglected field of research. Moreover, previous studies have stated that the placebo response is greater in pediatric patients than in adults and that a reduction in the attack frequency in the absence of any pharmacological treatment is observed more frequently in pediatric migraine patients than in adults. Besides these preliminary considerations, the shorter duration of migraine attacks and other characteristic semeiological features of the clinical picture in children are such that the design of randomized controlled trial (RCT) is more problematic in the developmental age than in the adult. Bearing in mind all these weak points, the aim of this review was to summarize and update recent guidelines for the treatment of primary migraine in children and adolescents. The most recent guidelines are those published by the Italian Society for the study of Headache, the French Society for the study of Migraine and Headache, and the American Academy of Neurology. We have incorporated into these guidelines the results from the few, recent RCTs, clinical controlled trials, open-label studies, meta-analyses and reviews that have been published since 2004; owing to the lack of strong evidence in this field of research, we have sometimes even mentioned pilot non-controlled studies, case series and expert opinions. Lastly, evidence was classified and the recommendations were categorized according to different levels.

Hypohidrosis-related symptoms in pediatric epileptic patients with topiramate

BACKGROUND

Topiramate is one of the most commonly prescribed newer antiepileptic drugs. However, we have encountered quite a few cases of pediatric epileptic patients on topiramate complaining about the symptoms related to hypohidrosis. The aim of this study was to determine the incidence and define the clinical characteristics of hypohidrosis-related symptoms with topiramate in pediatric patients.

METHODS

Data was collected prospectively on 264 patients diagnosed as having epilepsy and treated with topiramate at the Department of Pediatrics, Chonbuk National University Hospital between July 2004 and July 2006. The data were collected by direct interview after at least 3 months had elapsed from the initiation of the medication.

RESULTS

The study group was composed of 70 boys and 81 girls, with a mean age of 33.1 +/- 43.2 months. The mean duration of topiramate treatment was 13.4 +/- 15.0 months; 52 patients (34.4%) were treated with topiramate only and 99 patients (65.6%) were on polytherapy including topiramate; 59 out of 151 patients (39.1%) experienced hypohidrosis-related symptoms: such as facial flushing, lethargy, itching sensation, irritability with hyperthermia, heat sensation or heat intolerance. However, there were no patients complaining of hypohidrosis-related symptoms among those who were taking antiepileptic drugs other than topiramate.

CONCLUSIONS

Our results suggest that topiramate induces hypohidrosis-related symptoms more often than we expected, especially in pediatric patients. We recommend that pediatric epileptic patients taking topiramate should be warned to avoid hot and humid environments, especially during the hot summer season.

Role of antiepileptic drugs as preventive agents for migraine

Migraine is a common neurological disease affecting about 12% of the population in Western Europe and North America, and causing a considerable burden both to migraineurs and to society. Severe, frequent and disabling migraine attacks, as well as those poorly responsive to acute care medication, require preventive treatment, which is often under-utilized. Antiepileptic drugs are used in the prevention of migraine. We performed a literature search of PubMed through June 2008 for controlled trials of antiepileptic drugs in the prevention of migraine. The search identified 70 papers for a full-text review. The majority of these papers referred to valproate and topiramate, and showed that these drugs are effective and well tolerated in migraine prevention and are suitable for first-line clinical use. On the other hand, acetazolamide, lamotrigine, oxcarbazepine and vigabatrin have been shown to be not effective and gabapentin requires further evaluation. For the rest of the antiepileptic drugs, no data from controlled trials are available.

Divalproex extended-release in adolescent migraine prophylaxis: results of a randomized, double-blind, placebo-controlled study

OBJECTIVE

To evaluate the efficacy, tolerability, and safety of 3 different doses of divalproex sodium extended-release vs placebo in the prophylaxis of migraine headaches in adolescents.

BACKGROUND

Divalproex sodium has been approved for migraine prophylaxis in adults, and previous uncontrolled data suggest divalproex sodium may be effective in preventing migraine in children and adolescents with acceptable tolerability.

METHODS

This was a 12-week, phase 3, randomized, placebo-controlled, double-blind, parallel-group, multicenter study in approximately 300 adolescents aged 12 to 17 years with migraine headaches. At the end of the baseline phase, subjects still meeting study criteria were randomized in a 1:1:1:1 ratio to receive divalproex sodium extended-release 250 mg, 500 mg, or 1000 mg once daily, or placebo. The primary efficacy variable was reduction from baseline in 4-week migraine headache rate for each active treatment group vs placebo. Standard safety assessments were conducted and testosterone and sex hormone-binding globulin levels were collected for postmenarchal females.

RESULTS

There was no statistically significant treatment difference between any divalproex sodium extended-release dose group and placebo for the primary efficacy variable, reduction from baseline in 4-week migraine headache rate. There were no statistically significant differences in adverse events between any active treatment group and placebo. A notable dose-related decrease in platelets was observed, and individuals in all 4 treatment groups had increases in ammonia levels; treatment differences in other laboratory variables were generally small. Among postmenarchal female subjects who were not taking hormonal contraceptives or other steroids, there was no statistically significant change in testosterone levels, but a statistically significant dose-related increase in sex hormone-binding globulin was observed.

CONCLUSIONS

In the current study, divalproex sodium extended-release did not differentiate from placebo in the prophylactic treatment of migraine headaches but was generally well-tolerated in adolescents aged 12 to 17 years.

Utility of Topiramate for the Treatment of Patients with Chronic Migraine in the Presence or Absence of Acute Medication Overuse

Chronic migraine has been linked to the excessive use of acute headache medications. Medication overuse (MO) is commonly considered the most significant risk factor for the progression of migraine from an episodic to a chronic condition. Managing MO is a challenge. Discontinuation of the acute medication can result in withdrawal headache, nausea, vomiting and sleep disturbances. This review summarizes the results from two similarly designed, randomized, placebo- controlled, multicentre studies of chronic migraine conducted in the USA and European Union. Both studies demonstrate the efficacy and safety of the migraine preventive medication, topiramate, for the treatment of chronic migraine in patient populations both with and without MO. These studies may have important implications for the future of chronic migraine management, suggesting that detoxification prior to initiating prophylactic therapy may not be required in all patients if MO is present.

Efficacy and tolerability of topiramate in pediatric migraine

About 5-10% of school-age children manifest migraine headaches. Treatment options for pediatric migraine are limited. Topiramate is approved for migraine prophylaxis in adults, but its use in children is limited. We retrospectively reviewed the records of 37 patients, i.e., 22 (60%) girls and 15 (40%) boys (mean age, 14 years; range, 7.3-20.5 years), diagnosed with migraine without aura in 30 (81%), with aura in four (11%), and abdominal, ophthalmoplegic, and catamenial in one each. The mean follow-up was 12 +/- 5 months standard deviation (S.D.). Clinical response was qualified as excellent, good, no change, or worse. Numbers of headaches per month were 15 +/- 7 S.D. prior to treatment and 3 +/- 3.4 S.D. (P < 0.001) after treatment. An excellent or good response (>50% migraine reduction) was attained in 28 patients (76%). Ten (27%) patients exhibited adverse effects. Patients taking >2 mg/kg/day were more likely to demonstrate side effects. The mean dose for patients without adverse effects was 1.27 +/- 0.7 mg/kg/day S.D. Those who reported adverse effects were taking a mean dose of 2.8 +/- 1.5 mg/kg/day S.D. This study demonstrated that topiramate is an effective, safe alternative for the prophylaxis of pediatric migraine. An acceptable risk/benefit maintenance dose was < or =2 mg/kg/day.

Placebo Efficacy in Childhood and Adolescence Migraine: An Analysis of Double-Blind and Placebo-Controlled Studies

Studies on the treatment of migraine in children and adolescents are rare and difficult to design. In particular, the high placebo response in some trials makes it difficult to prove efficacy of a verum drug. We analysed all available placebo-controlled trials on acute and on prophylactic migraine treatment in children and adolescents with respect to different placebo rates (pain free and pain relief at 2 h; rate of responders with ≥ 50% attack frequency decrease). We identified eight crossover and 11 parallel group trials on acute treatment. The placebo response rates were considerably lower in crossover trials than in parallel group trials (19.2% vs. 27.1% for pain free after 2 h and 39.4% vs. 56.9% for pain relief after 2 h). In the 10 prophylactic trials included in this analysis, only a small trend towards a lower placebo rate in crossover trials could be observed. Further significant factors associated with a lower placebo rate in childhood and adolescence trials on the acute treatment of migraine were single-centre (vs. multicentre) trials and small sample size. Age and sex were not associated with the placebo response. Our study suggests that parallel group trials on the acute treatment of migraine in children and adolescents show a very low therapeutic gain due to a high placebo rate. The verum response rates, however, are very similar to those seen in adulthood trials. In conclusion, trial designs on the acute and prophylactic treatment of migraine in children and adolescents should consider the specific findings of this analysis in order to exhibit a higher probability of showing significant differences between placebo and verum drug.

Anticonvulsant drugs for pediatric migraine prevention: an evidence-based review

BACKGROUND

The use of anticonvulsant drugs for the prevention of migraine in children and adolescents has been supported in the past.

AIMS

To evaluate the available evidence for the efficacy and safety of anticonvulsants drugs in the prevention of migraine attacks in children and adolescents.

METHODS

Studies were selected through a comprehensive literature search. We included all types of study designs (controlled and uncontrolled) due to the limited evidence. Monthly migraine frequency was used as the primary outcome measure in most of the studies. Studies were classified into levels of evidence according to their design.

RESULTS

Fourteen studies were included with a total of 939 patients. Topiramate (4 randomized controlled trials [RCT], two uncontrolled trials), sodium valproate/divalproex sodium (two RCTs, one uncontrolled trial, two retrospective chart reviews) levetiracetam and zonisamide (both only uncontrolled studies) are the anticonvulsants that have been reported in the literature. The findings show that valproate is not different from placebo and topiramate may not be different but further randomized trials are needed. All drugs were well tolerated in this age group with no serious events reported.

CONCLUSIONS

The use of anticonvulsants in the prevention of migraine in children and adolescents is not adequately supported by methodologically sound RCTs. More research is needed in the future to establish the efficacy and safety of specific agents.

Modern Management of the Migraine Headache

Migraine headache is a debilitating disorder that affects millions of people in the United States and worldwide. The diagnosis of migraine can significantly affect quality of life, health care costs, and daily productivity. Hundreds of trials and many guidelines have documented various approaches to migraine management, whether via acute treatment or chronic migraine prophylaxis. Acute or abortive migraine management encompasses specific and nonspecific migraine therapeutics, including nonopioid and opioid analgesics, triptans, and ergotamines. Prophylactic migraine management data span the pharmacological spectrum from antiepileptic and antihypertensive agents to botulinum toxin type A. Special considerations for migraine management also must be applied in various populations, including children, pregnant women, and the elderly. The following review serves as an introduction to current therapeutic approaches for acute migraine treatment and provides an overview of available literature for pharmacological prophylaxis.

[Antiepileptic drugs in pediatric migraine]

According to the criteria of the International Headache Society, migraine occurs in approximately 5 to 10% of children. As many as 30% of young patients with migraine experience such frequent and disabling attacks, or have unsatisfactory results and/or experience adverse effects with pharmacologic treatment of acute migraine attack, that daily preventive medications are required. Many studies have investigated the use of antiepileptic drugs in this indication but there is a paucity of placebo-controlled studies. So far, in the setting of migraine with and without aura, only flunarizine and topiramate have proved their efficacy in more than one placebo-controlled study. Uncontrolled studies suggest the possible efficacy of valproic acid, gabapentin, levetiracetam, zonisamide, and magnesium in preventive therapy of childhood periodic syndromes. Most of antiepileptic drugs used in pediatric preventive therapy are well tolerated. The most common adverse events are asthenia and somnolence.

Pediatric headache

PURPOSE OF REVIEW

Headaches occur frequently in the pediatric population and have a significant impact on both the patient and their family. Migraine, the most common headache disorder for which patients see a physician, still remains underdiagnosed and undertreated. Recent studies have revealed the increasing incidence of migraine and chronic migraine in the pediatric population.

RECENT FINDINGS

Limitations of the present diagnostic criteria for migraine are presented, and the proposed modifications to these criteria may assist you with early recognition and ultimate treatment. New acute and preventive migraine treatment data demonstrating statistically significant benefit for the primary endpoints will be reviewed in detail. The clinically relevant impact of migraine on the pediatric patient documented by the use of the Pediatric Migraine Disability Assessment and the Pediatric Quality of Life Inventory will be discussed.

SUMMARY

A comprehensive management approach blending the most current acute, preventive, and biobehavioral treatments will be reviewed. Further research, with novel study designs, in pediatric headaches is needed to help reveal additional pathophysiological mechanisms, improve diagnostic criteria, and advance optimal treatment. Prospective studies are needed to fully evaluate the efficacy of preventive management in this population and to establish whether early intervention might slow this disease progression.

Pain therapy in children and adolescents

INTRODUCTION

In children, acute pain occurs predominantly during infectious illnesses or after surgery. Chronic pain, especially headache and abdominal pain, is becoming increasingly common among children and adolescents.

METHODS

Selective literature review, also including evidence-based guidelines and recommendations.

RESULTS

Simple self-reporting and behavioral pain scales are easy to use to assess the intensity of acute pain. To evaluate chronic pain, on the other hand, more complicated, multi-dimensional instruments are necessary (e.g., semi-structured interviews). The most commonly used analgesics are ibuprofen and paracetamol (acetaminophen). When paracetamol is used, its narrow therapeutic window should be kept in mind. Perioperative pain should be treated with balanced analgesia involving a combination of non-pharmacological treatment strategies, non-opioid drugs, opioids, and regional anesthesia. Chronic pain in children can only be treated successfully over the long term with multidisciplinary team intervention based on this biopsychosocial model.

DISCUSSION

Pain not only causes children momentary suffering but also threatens to impair their normal development. Therefore, every effort should be made to prevent pain and to treat it effectively once it arises.

Topiramate in the prevention of pediatric migraine: literature review

Pediatric migraine is a disabling condition, which can cause a significant impact on quality of life. Currently, no drugs have been approved by the FDA for its preventive treatment. Our aim was to review the medical literature concerning the efficacy and tolerability of topiramate in the prophylactic treatment of migraine in children and adolescents. A total of five papers were reviewed: two randomized controlled trials (RCTs), a post-hoc subset analysis of adolescents who had been included in three RCTs carried out on adults and two open studies. Topiramate has been proven to reduce headache frequency and the accompanying disability. The frequency of side effects varied considerably among studies, the most frequent being weight loss, anorexia, abdominal pain, difficulties in concentrating, sedation and paresthesia. Since these adverse events, although often transitory, may be distressing for the child, we strongly recommend to assess the disability caused by the migraine episodes before deciding to initiate a prophylactic treatment. Nevertheless, dropout rates due to side effects in the studies were very low.

Headaches

PURPOSE OF REVIEW

Headaches and migraine occur frequently in children and adolescents and may have a significant impact on the child's and parents' lives. Recent advances in diagnosis, epidemiology, and treatment have improved the outcomes of children with headaches. This review summarizes some of these findings.

RECENT FINDINGS

Recent studies have revealed the increasing incidence of migraine and chronic migraine in the pediatric and adolescent age groups. These studies have also begun to identify comorbidities that may affect the impact over a lifetime. Limitations of the diagnosis of migraine have restricted some of these findings, but modifications to the criteria may assist with early recognition. Proper evaluation and treatment, including acute, preventive, and biobehavioral therapies, may need to be incorporated for optimal outcomes. Long-term outcomes may be determined by the underlying pathophysiology as well as early effective management.

SUMMARY

Migraine in children is increasingly being recognized as a problem. Early, effective treatment is available and may result in long-term benefit and prevent disease progression. Further research into childhood headaches should help reveal additional pathophysiological mechanisms and treatment options.

Topiramate for migraine prophylaxis

Topiramate is one of several antiepileptic drugs that are used in the prevention of migraine, but the only one licensed for use in the UK. Topiramate has an extensive evidence base provided by double-blind, placebo-controlled trials to show that it is a safe, effective and well tolerated drug in the management of migraine. It has also been shown to have a role in the management of chronic migraine, which represents a challenge to primary care clinicians as well as headache specialists. Studies have demonstrated that topiramate can also be effective in preventing migraine in childhood and adolescence, although this is unlicensed in the UK. It has been shown in models both in the US and the UK to offer a cost benefit when direct and indirect costs are evaluated by reducing work loss, improving quality of life and reducing the use of increasingly scarce health resources.